Chapter 3: Beyond the Symptoms: Generalizations and Distinctions between Eating Disorders with Different Symptom Manifestations in Psychoanalysis

ABSTRACT

In this article, I attempt to describe in detail the eating disorders of anorexia and bulimia. Although often lumped together as the same kind of eating-disordered pathology, I explore, in part by using my personal experience, how their origins and symptoms are different and why their psychoanalytic treatment modalities need to be responsive to these differences.     

Establishing partial limits on children's behavior: Use of strategic,structural, and cognitive-behavioral approaches

Abstract

Playful wrestling, splashing, fidgeting, chair-tilting, and a number of other behaviors by children often result in injuries, tantrums, or conflicts in families. Unlike most behaviors of children which can be specified by parents as acceptable or unacceptable, each of these behaviors is only partially acceptable and the limits of acceptable behavior are impossible to specify in verbal terms; these limits can only be determined by the child after the limits have been exceeded. Exact limits can be established in these instances with an intervention which integrates strategic, structural, and cognitive-behavioral approaches. Two case examples are presented and the ingredients which appear essential to the intervention are discussed.     

Seeing and Being Seen: Courage and the Therapist in Cross-Racial Treatment

ABSTRACT

Correction of the patient's distortion is often the focus of therapeutic treatment. However, the therapist's distortions, based upon pre-existing fears, which themselves are often rooted in greater societal issues and energized by the work with the patient (especially as they relate to issues of racial difference between the therapist and patient), can lead to clinical impasse. Just as an effective treatment relies upon the patient's opening up to correcting distortions, so too the therapist must be able to use transference response and become vulnerable to knowing and moving beyond his own fears and distortions.     

Effects of Behavioral Group Therapy on chronic Pain

Abstract

Benign chronic pain is frequently reported among rehabilitation patients. The present study investigates a behavioral treatment model used with 3 consecutive groups of 8 chronic pain outpatients. The behavioral strategy used was to identify specific pain behaviors such as verbal expression of pain, consumption of analgesics and inactivity and to teach the patient to modify these patterns. The treatment was provided by a rehabilitation team and included contingency management of pain behaviors, applied relaxation and social skills training. Results showed significant 6 month follow-up reductions in the expression of pain, analgesics intake and level of rest for the group as a whole subsequent to intervention. In addition, two thirds of the group were engaged in formal pre-occupational training at follow-up.     

Mentalization-Based Interventions in Child Psychiatry and Youth Protection Services I: Objectives,Setting, General Principles and Strategies

ABSTRACT

Many of the children who receive services in child psychiatry or are in the care of Youth Protection Services present with complex, multiple and often severe problems. Classic psychodynamic psychotherapy seems to be of little benefit to them. The majority of these children tend to not use symbolic play as a means of expressing their intrapsychic conflicts or relational difficulties and they do not verbally communicate much with clinicians. They are more likely to display an imaginative poverty that translates into boredom, motor discharge, and an inability to use the material put at their disposal for therapeutic purposes. The systematic and rigorous observations of these children in Quebec revealed that the majority of them present with severe mentalizing difficulties. They often show attitudes and behaviors linked to the prementalizing modes of psychic functioning. This article presents a mentalization-based intervention adapted to these children’s difficulties. The objectives, adaptation of the work setting, and general principles underlying this intervention are discussed. In addition, general intervention strategies are also covered. These interventions are considered as preparatory work whose principal purpose is to enable children to benefit later on from psychodynamic psychotherapy. The authors also recommend specific intervention strategies adapted to children’s predominant mode of psychic functioning. The details of these strategies will be shared in a separate article.     

Internet-based parent management training: a randomized controlled study

ObjectiveThe current study evaluated the efficacy of an Internet-based parent-training program for children with conduct problems. Dose–response ratio and costs for the program were also considered.MethodParents of 104 children (aged 3–12 years) were randomly allocated to either parent training or a waitlist control condition. Diagnostic assessment was conducted at baseline and parent ratings of child externalizing behaviors and parent strategies were completed before and after treatment and at 6-month follow-up.ResultsAt post-treatment assessment, children whose parent(s) had received the intervention showed a greater reduction in conduct problems compared to the waitlist children. Between group intent-to-treat effect sizes (Cohen’s d) on the Eyberg Intensity and Problem scales were .42 and .72, respectively (study completers .66 and 1.08). In addition, parents in the intervention group reported less use of harsh and inconsistent discipline after the treatment, as well as more positive praise. Effects on behavior problems were maintained at 6-month follow-up.ConclusionsThe results support the efficacy of parent training, administered through Internet, with outcomes comparable to many of the group-based parent training programs. The efficacy, low cost, and higher accessibility make this intervention a fitting part in a stepped-care model.     

Eating disorders as psychosomatic illness the implications for treatment

Abstract

This paper describes a body of theory which points to the possibility that eating disorders can be seen as psychosomatic illness, which is to say a symbolization of affect via the body rather than with words. The author concludes from this that eating disorders may respond better to non-verbal experiential therapies than they do to verbal therapy. She then describes four years of work with groups of eating-disordered women using non-verbal experiential therapies and suggests that the improvement in their symptoms may be the result of these methodologies and that her hypothesis merits further testing and exploration.     

La photo-expression : un outil pour accompagner le patient en éducation thérapeutique et pour évaluer son évolution

IntroductionIn therapeutic patient education (TPE), photoexpression is often used by psychologists in order to work on patients’ perceptions and experiences, especially in group workshops.AimThe aim of this study was to explore diabetic patients’ discourse during two photoexpression group workshops at the beginning and the end of a TPE program.MethodSeventeen patients took part in this study. A lexicometric analysis was performed on their discourse during the two group workshops (Alceste® software).ResultsFor the first workshop, the analysis yielded two classes: the place of diabete in daily life as well as psychic and social functioning. For the second workshop, the analysis also yielded two classes: self-management and adjustement, as well as program experience and return back home.ConclusionThe results show an increase in adaptation skills and particularly in self-efficacy, motivation, positive emotions, perhaps illness acceptance. Photoexpression shows to be a very interesting tool in TPE to accompagny patients but also evaluate their discourse evolution during a TPE program.     

Momentary affective response to bouts of moderate-to-vigorous physical activity predicts changes in physical activity and sedentary behavior during behavioral weight loss

BackgroundAffective responses are posited to be key predictors of the uptake and maintenance of health behaviors. However, few studies have examined how individuals’ affective response to physical activity, as well as the degree to which their affect response changes, may predict changes in physical activity and sedentary time during behavioral weight loss treatment.PurposeThe current study examined how baseline momentary affective response (i.e., stress and anxiety) to moderate-to-vigorous physical activity (MVPA) and the degree of pre--post intervention change in this response predicted change in daily sedentary, light, and MVPA time during a three-month internet-based weight loss program.MethodsWomen with overweight/obesity (final N = 37) completed 14-day ecological momentary assessment (EMA) protocols with objective measurement of physical activity (i.e., bout-related MVPA time) before and after the intervention.ResultsWomen who had more reinforcing responses to MVPA (i.e., greater reductions in anxiety and stress response following MVPA bouts) at baseline had greater increases in overall MVPA at the end of the intervention. Those who had greater anxiety reductions after MVPA bouts at baseline also evidenced less sedentary time at the end of the intervention. Changes in affective responses across the intervention were not related to changes in physical activity levels.ConclusionsFindings suggest initial levels of affective reinforcement from MVPA bouts predict future change in MVPA and sedentary time during behavioral weight loss. Future work is needed to examine the utility of more precisely targeting affective responses to physical activity to optimize intervention approaches.     

‘Mill’s Liberal Project and Defence of Colonialism from a Post-Colonial Perspective’

Abstract

Whilst this paper was initially part of a larger project tracing the development of Anglo-American thought from the colonial through to the post-colonial era, below it stands alone as reflection on the colonialism of John Stuart Mill read from a post-colonial perspective. It aims to show that Mill’s views on colonial rule were largely informed by his principle of liberty which, in turn, was based on his qualitative utilitarianism. The driving force behind his colonialism, as with his work in general, was his unwavering belief in the importance of human progress and development. Mill never believed, as did many of his contemporaries, that the ‘backward’ societies of the colonies were inherently inferior, but rather that they needed paternal intervention from more civilised, progressive societies in order to stimulate growth in that spontaneous human development was not inevitable. When read in this light Mill’s views on colonial rule, while culturally bigoted and ethnocentric, appear less contradictory to his liberalism as a whole.     

Eating Disorders—The Regulation of Positive as well as Negative Emotion Experience

Disordered eating behaviors are often conceptualized as maladaptive emotion regulation strategies. The present study investigated links between emotional experience, schematic belief systems, and psychological themes associated with eating disorders. In contrast to the majority of studies, which focus on just one or two emotions and use nonclinical samples, this study compared the full range of emotional experience in women with eating disorders to a control group. Measures used include the Differential Emotional Scale-IV, Youngs Early Maladaptive Schema Questionnaire, and Eating Disorder Inventory-2. The study provides the first empirical evidence that women diagnosed with eating disorders report experiencing pleasant as well as unpleasant emotions more frequently than do controls. A surprising finding was that pleasant emotions (joy, interest, surprise) correlated with eating disorder themes (EDI-2 subscales) more consistently than unpleasant emotions in the eating disorder group, while the reverse was true of the control group. Also of note, eating-disordered women reported significantly less anger and similar levels of fear vs. controls. While eating-disordered women scored more highly than do controls on all maladaptive schema (suggesting high levels of distress in women with eating disorders), the pattern of correlations between schema and emotion experience was distinctly different for each group and counterintuitive for the eating disorder group. In particular, pleasant emotion was highly correlated with maladaptive schema in the eating-disordered group but not in the control group. These marked group differences in the pattern of relationships between emotion experience, eating disorder themes, and belief systems suggest that it is not valid to draw conclusions about eating disorders from research that employs only nonclinical samples. The authors discuss these findings, and suggest that women with eating disorders are proficient at using disordered eating behaviors to manipulate their experience of both positive and negative emotional states, and that this dynamic should be recognized as an important maintenance factor.     

Growth: What reconciliation of conflicts could mean. A lesson from the history of psychoanalysis

Abstract

Often, conflicts cannot be solved; they have to be endured. A hidden idea behind solving conflicts and coming to reconciliation is growth, but what does growth mean? Here growth is understood as the use of different perspectives: at first different perspectives, then their complementary use, followed by their simultaneous use, and then achieving a state of resonating alignment. Finally, growth is described as gaining excentric positionality, introducing a concept from the philosopher Hellmuth Plessner. The author shows these steps from different to complementary to simultaneous use and resonating alignment not by clinical material, but by using the history of the theoretical evolution of psychoanalysis. Growth is an important concept not only for patients, but also for understanding our history.     

Juegos en Dinamica de Grupo (Games in Group Dynamics)

Abstract

It is widely recognized that military service during wartime can take a toll on a soldier’s psychological health. Recent work has revealed effects on the families left behind as well, as reflected, for example, in an increase in child abuse and neglect in these families. My interest in studying the transgenerational transmission of trauma led me to offer the National Guard a pro bono group therapy for women whose husbands had been deployed overseas. A slightly unorthodox approach paved the way not only to group treatment but, ultimately, individual treatment for these women and their children. My hope is that this work can serve as a model for other therapists who share my interest in treating the intergenerational transmission of trauma by implementing group and mother-child psychotherapy.     

Receptivity,or Going on (Not) Being: Commentary on Paper by Robert Grossmark

“The treatment hinged on my being able to live with him in this ongoing non-existence and know it and tolerate it, and expect no more,” writes Dr. Robert Grossmark about himself and his patient, Kyle (pp. 637–638). This is a key sentence, outlining the core of the enlightening analytic work done. I comment on the linkage between living the ongoing nonexistence and going-on-(not)-being, then reflect about the distinction between what I call the “outward” technique, which is everything Grossmark describes about treating Kyle, and the “inward” technique, which is all that occurred within him, in an inner, hidden, powerful, unconscious dialogue with the patient, and which is only hinted at. In this context, with patients like Kyle, who bring to the analyst physical sensations and actions for dreaming, the analyst's corporeality, by which I mean his experience of his body and his capacity to connect it to emotion, thereby lending it meaning, has a critical importance. I bring, in a nutshell, references to several psychoanalytic writers about the subject of corporeality in analytic treatment and use a vignette from an analysis to demonstrate the point.     

The Lidcombe Program of early stuttering intervention for Malaysian families: Four case studies

PurposeThis study investigated the outcomes of implementing the Lidcombe Program, an evidence-based early intervention for stuttering, with four preschool children in Malaysia. Early stuttering intervention is currently underdeveloped in Malaysia, where stuttering treatment is often more assertion-based than evidence-based. Therefore, introducing an evidence-based early stuttering intervention is an important milestone for Malaysian preschoolers who stutter.MethodThe participants ranged from 3 years 3 months to 4 years 9 months at the start of the study. Beyond-clinic speech samples were obtained at 1 month and 1 week pretreatment and immediately post-Stage 1, and at 1 month, 3 months, 6 months and 12 months post-Stage 1.ResultsTwo participants, who were bilingual, achieved near-zero levels of stuttering at 12 months posttreatment. Near zero levels of stuttering were also present in their untreated languages. One participant withdrew due to reasons not connected with the research or treatment. The remaining participant, who presented with severe stuttering, completed Stage 1 but had some relapse in Stage 2 and demonstrated mild stuttering 12 months post-Stage 1.ConclusionsThe outcomes were achieved without the need to significantly adapt Lidcombe Program procedures to Malaysian culture. Further research to continue evaluation of the Lidcombe Program with Malaysian families and to estimate proportion of those who will respond is warranted.     

三维干预促进小学生心理健康的研究

为了探索有效的小学生心理健康教育模式,以昆明市两所普通小学分别作为实验组和对照组进行了为期两年的实验研究,对影响小学生心理健康的主要因素:教师、家长和学生自身三个子系统进行了多侧面的三维干预。结果表明:(1)实验组学生比对照组学生的总体一般焦虑水平下降;(2)学习适应性提高;(3)问题行为症候群的学生人数和问题行为比干预前明显减少。验证了教师、家长、学生三维干预结合模式对促进小学生心理健康的有效性。     

Mending the Mind

Cognitive behavior therapy (CBT) offers an alternative paradigm to psychoanalysis for understanding human behavior and the mechanisms of change. Dialectical behavior therapy (DBT) grew out of this tradition conceived originally for the treatment of suicidal patients with borderline personality disorder. Unlike psychoanalysis, DBT does not recognize unconscious meanings or motivations and instead focuses on sequences of measurable behavior and the contingencies that reinforce them. The treatment protocol emphasizes a deficit model and is structured around specific targets and goals combined with “skills” training (i.e., specific skill sets to help with emotional, cognitive, and behavior dysregulation) Combining an overarching dialectical philosophy, emphasis on the therapeutic relationship and mindfulness, DBT offers a comprehensive therapeutic approach including individual sessions and group work.

The directive methods of CBT have often been viewed as antithetical to analytic reflection; such active therapeutic techniques on the part of the psychoanalyst are often seen as impeding the necessary free associative processes necessary for the acquisition of insight and for change. Whereas psychoanalysts help patients recognize dysfunctional patterns of behavior within the transference and alternative ways to view the transaction, they often do not help a patient implement new behaviors into their lives in systematic ways.

Both psychoanalysis and DBT have much to offer and to gain. In time translation and mutual inclusion of new ideas may help bridge the gap.     

Manipulation of thinness and restricting expectancies: further evidence for a causal role of thinness and restricting expectancies in the etiology of eating disorders.

To test the eating disorder expectancy theory contention that expectancies for reinforcement from thinness play a causal role in body dissatisfaction and eating disorder symptoms, the authors manipulated expectancies in 2 studies. Participants were exposed to either a psychoeducational intervention or an experimental manipulation of thinness and restricting expectancies. Study 1 participants were symptomatic college women who attended 3 experimental sessions and 1 follow-up session, each 1 week apart. Study 2 participants were high school girls who received the 3 experimental sessions clustered into 2 meetings; they completed symptom measures at baseline and at follow-up. In both samples, the thinness expectancy manipulation produced greater declines in thinness expectancies and body dissatisfaction than did the psychoeducational intervention. For high school girls, the thinness expectancy manipulation also produced a greater decline in overall eating-disordered attitudes. These results provide further support for the role of expectancies in the etiology of eating-disordered behaviors.     

Child and family therapy: A collaborative approach

Abstract

When a child is the identified patient, people often expect individual sessions to be a part of treatment. Yet, family therapists routinely violate this expectation by working with children solely in the context of the family. This article discusses how the therapeutic process can be facilitated by conducting at least a small number of individual sessions with children. Such behavior by the therapist communicates to children, parents, and involved referral sources a respect for their opinions and lays the groundwork for cooperation. The advantages and disadvantages of such an approach are discussed.     

Treatment of a four-year-old victim of incest

Abstract

A case study describing the use of behavior techniques in the treatment of a four—year—old sexual assault victim is presented. The target behaviors included eating, phobic behaviors, self—injurious behaviors, and comments made about the father (the perpetrator) and the paternal grandmother. The child's mother served as both data collector and therapist. The study demonstrates that child victims can experience a sexual assault trauma syndrome similar to that manifested by adult victims. Additionally, the findings illustrate that a simple behavioral intervention implemented by a parent can be effective in treating young sexual assault victims.