Bite by Bite: Working with Eating Disorders Using Accelerated Experiential Dynamic Psychotherapy, Jessica Slatus -Volume 8
Jessica K. Slatus, LCSW
Abstract. For clients with eating disorders, food is a medium of emotional expression. Helping the client to develop a greater awareness of her affective experience, and to expand her capacity to internalize nourishing relational experiences, is critical to fostering sustained recovery. Accelerated Experiential Dynamic Psychotherapy (AEDP), with its explicit, experiential focus on privileging new and positive experiences of affect and connection, is well-suited to this work. This paper will offer strategies to appreciate and disarm the eating disorder client’s defenses, highlight specific AEDP interventions that foster receptivity to positive affects from the therapist as well as from other parts of the self, and illustrate the therapist modeling receptivity for the client.
“The time will come
when, with elation
you will greet yourself arriving
at your own door, in your own mirror
and each will smile at the other’s welcome,
and say, sit here. Eat.”
– Derek Walcott, Love after Love
Clients with eating disorders often have trouble recognizing, modulating and expressing their emotional experience (Harrison et al., 2009, 2010; Ioannou & Fox, 2009; Kucharska-Pieture et al., 2003; Svaldi, et al., 2011). Their dilemma about what and how much to take in and “what [to] do with it once it is inside of them” (Schneer, 2002, p. 161) extends beyond the realm of food, manifesting itself in difficulty tolerating feelings and staying emotionally engaged and vulnerable in their relationships with others. When these dynamics emerge in psychotherapy sessions they present prime opportunities for the therapist to intervene to facilitate a new and positive experience for the client. Much like helping the individual develop the ability to feed herself mindfully and in response to her physical need, building the client’s capacity to take in and feel nourished by a wide range of affective, somatic, and relational experiences is central to sustained eating disorder recovery.
Accelerated Experiential Dynamic Psychotherapy (AEDP, Fosha, 2000b) is an attachment-oriented treatment approach that privileges moment-to-moment awareness and reflection of emotional and interpersonal processes as they emerge in session. Its emphasis on accessing and fully processing core experiences of emotion and connection makes it well-suited for working with clients with eating disorders, whose routine struggles include difficulty metabolizing internal experience and taking in, and making use of, relational experience. In AEDP, the unit of intervention is both what the therapist does and how the client responds (Fosha, 2002); it puts receptivity and the fostering of receptive affective capacity at the forefront of its practice. From the first moments of an AEDP treatment we are focused on expanding new and transformational experiences of the client’s self and her self-in-relation to others, making these changes explicit and experiential so that they can become integrated, readily available tools for self-regulation. In practice this means lingering at the juncture of new experience to help the client process the shifts that are occurring and fully take in the positive affects associated with this transformation. The combination of moment-to-moment tracking and metaprocessing (Fosha, 2000b) that is the hallmark of the model is the experiential antidote to being alone with overwhelming emotion and offers the opportunity for the client and therapist to titrate and integrate these new experiences in measure.
For clients with eating disorders, the ability to receive and hold on to positive affects is a clinical milestone to be reinforced and celebrated. The experiencing of positive emotions leads to “broadened thought-action repertoires” that build resiliency and help the client to develop tools and resources for coping with future difficulties (Frederickson, 2001, p. 220). Using receptivity as both a lens and a treatment target for working with eating disorders, this paper will offer strategies and interventions to help the clinician elicit and cement felt moments of connection and harness these experiences to help the client build secure attachment and secure internal attachment (Lamagna & Gleiser, 2007; Lamagna, 2011). This includes tracking and seizing glimmers of emotion, health, and resilience while also seeking out opportunities to befriend and undo the aloneness of the eating disorder part of the client (Costin, 1996); fostering openness to love and positive affects from the therapist, and compassion and caretaking from other parts of the self (Lamagna & Gleiser, 2007; Lamagna, 2011); and modeling receptivity to positive affects (Hanakawa, 2012) so that the client has an experience of being received in return.
The First Bite: Making Contact and Undoing Aloneness
Starting from a place of deep and genuine appreciation of the adaptive function of symptoms, the AEDP therapist is attuned, authentic, and actively affirming, seeking to undo aloneness and establish secure attachment from the first moments of treatment (Fosha, 2000b). For clients who may not have experienced reliable caregivers in their early lives, the eating disorder itself functions as an attachment figure (Schwartz, Gleiser & Galperin, 2009); its attendant rules and mandates offer stand-in comfort, caregiving and containment to manage overwhelming emotions and cope with traumatic experiences (Schneer, 2002). Establishing a positive experience of attachment with the therapist creates a new avenue of soothing and regulation, lessening the need for the eating disorder.
Helping the client to have a non-threatening experience of feeling seen by the therapist is a fundamental aspect of healing trauma and building trust in the present relationship. For the eating disordered client, this includes making contact with all parts of her: healthy and sick, resilient and self-destructive. While we look for and highlight evidence of growth and strivings towards healing in AEDP, it is vital that we simultaneously seek out opportunities to accompany the part of the client that is deeply struggling with food. Specifically, honoring and befriending this part of the client and validating her need for the eating disorder is critical if one is to help the individual who is mired in her symptoms access and deepen into emotional experience. We can do this in two ways: (1) explicitly expressing compassion and reframing the role of the eating disorder as her best attempt at self-care, and (2) offering language that resonates with the eating disorder part of her and, at the same time, highlights the arbitrariness of the symptom.
We offer kindness and compassion for the eating disorder to help the client internalize our care and build an internal sense of self-compassion towards her struggles. The client’s response to the therapist’s commentary—the degree to which she can take in this compassion and bestow it upon herself—helps us to get to know the quality of her attachment and her relationship to her internal experience and gives us a roadmap for how we will proceed in our work. Explicitly expressing empathy for the eating disorder and how it has served to protect or help the client is a multipurpose intervention which (1) models compassion for parts that are struggling; (2) undoes aloneness; (3) makes the client’s resilient capacity explicit; and (4) serves as what Ron Kurtz (2007) calls a “probe” to make something happen in the session. It is a particularly effective way in with clients who appear disconnected and are having trouble making contact with the therapist and observing and reporting on their emotional and somatic experience.
Working within the frame of AEDP, we endeavor to stay close to the client’s experience in the moment. Interventions such as “you’re nodding…” “a smile,” or “just check in inside…what happens when you hear me say that?” are examples of what Natasha Prenn (2011) calls experiential language that orients the client towards her internal experience and helps the dyad to transition “from talking about experience to actually experiencing and being in an experience together“(p.314). The opportunity for emotional healing becomes possible under conditions of safety (Fosha, 2002), and this intervention will either be met with green signal affects – glimmers of the client’s healthy, adaptive self that hungers for recognition (Prenn & Slatus, in press), e.g., tears in her eyes, a smile, nodding, expressing feeling seen/recognized, telling us to proceed, or red signal affects – anxiety or an attempt to block/undo the commentary, e.g., arguing the point, shrugging it off, directing anger and blame towards the self for using the eating disorder to cope; staying mired in anxiety and defense, telling us that more anxiety regulation needs to occur before she feels ready to go there (Fosha, 2000b). Moment-to-moment tracking of how the client is receiving the therapist’s comment, followed by metaprocessing, helps us to know to what extent she is absorbing the therapist’s compassion and makes explicit any parts of her that may be interfering with really taking this in (Fosha, 2000). Her reaction then informs our next intervention.
Another way to connect and build trust with eating disordered clients, particularly in the earlier stages of treatment when they are typically most anxious and defended, is to speak their language; in other words, using language that is easier to digest. Using food and weight metaphors is a “top-of-the-triangle” intervention, designed to create safety and gently draw attention to defenses (Fosha, 2002). It is a low-vulnerability way to connect and build attachment through play (Schore, 2001); it sets the stage for defense recognition by highlighting the incongruity of the symptom, i.e., “how did a cookie become a COOKIE!!” (Schneer, 2002, p. 165), and it provides the opportunity to do a small piece of work around the client’s reaction to the therapist and her choice of words.
Offering short statements such as “so much weight to carry around;” “it’s like you never get to fill up;” and “it’s really hard to keep it in” nearly always provokes some kind of response in the client. It playfully brings both the relationship between the client and her eating disorder, and the client and therapist, to the forefront, setting the stage for deeper intra-relational and relational work. Because, in AEDP, the opportunity to check in and process as we work is built into the model, the therapist’s statement is just the beginning (Fosha, 2002; Prenn, 2011). Much like post-meal processing groups commonly seen in eating disorder treatment programs, we want to know how this new experience is landing. In asking “how does it feel inside when you say x, y, or z?” or “what’s it like to do this with me?” we are asking “how is this meal going for you, here and now? How does this bite feel? And this one?” “Wow, you finished your meal! “What’s that like for you?” “What’s it like that I am noticing?” Repeated exposure to manageable bites of new experience followed by explicit and mutual reflection helps the client metabolize and integrate these experiences without overwhelm (Prenn & Slatus, in press). Interestingly, as we will see in one of the subsequent transcripts, clients often spontaneously offer this language at critical moments of change in the therapy, signaling the beginning of being able to integrate their understanding of their need for the eating disorder into their narrative.
Can You Take This In? Building Receptive Affective Capacity
The ability to take in love and accompaniment from another person is an essential ingredient in the establishment of secure attachment (Fosha, 2006a). Many clients with eating disorders also present with histories of attachment trauma (Farber, 2008; Tasca et al., 2012), making the experience of feeling nourished by their relationships a complicated one (Schwartz et al., 2009). Because the attachment relationship between the client and therapist is front and center in AEDP, there are a multitude of opportunities to provide a new experience of this bond and to help her to receive the therapist’s presence and care. These “experiences of, and strivings for, attachment, connection, intimacy, and closeness, including the ‘we’ affects of affective resonance and ‘in sync’ experiences” are what Fosha (2002, p. 321) calls core relational experiences that we seek to expand, strengthen, and help the client to integrate in order to achieve an earned secure attachment status (Siegel, 1999).
A number of AEDP interventions are particularly helpful for slowing down and harnessing these core relational experiences. In session the AEDP therapist is explicitly affirming, frank about her affection for the client, and self-disclosing of the client’s impact on her. Moment-to-moment tracking of nonverbals, including body language, affect, and relatedness, sets the stage for making explicit the relationship and the extent to which the client is receiving the therapist (Fosha, 2000b). By asking for the client’s internal somatic experience of the interaction we bring the work into the present moment, where the client is a having an experience of affect within the context of the new relationship with the therapist.
At the symptom level, clients with eating disorders have great difficulty processing and metabolizing: food is kept out, taken in and regurgitated, or swallowed whole without mindful reflection. The metaprocessing of the new experience with the therapist, if it can indeed be received, in turn produces positive affects associated with transformation, including pride, gratitude and feeling moved, amongst others (Fosha, 2000a; Russell & Fosha, 2008). Privileging the positive(Fosha, 200a), delighting in the client (Fosha, 2008), and judiciously using self-disclosure, followed by metaprocessing (Prenn, 2009), helps us to deepen the experience for both parties. Another round of metaprocessing of these affects facilitates access to core state (Fosha, 2005; Russell & Fosha, 2008), where the client has a more coherent narrative of herself and her life and is able to see and reflect on her defenses with truth and compassion.
In the transcript that follows, the client talks about a recent experience in which she was assertive with a friend about a rupture that occurred between the two of them. The client is a 35-year-old woman whose symptoms cycle through restriction, bingeing and periods of more attuned eating, dynamics that are elaborated in other areas of her life as well. This is our tenth session and I am explicitly acknowledging her bravery in addressing the issue, and actively working on helping her to stay with her sense of pride and take in my recognition and affirmation of the hard work she is doing. She has a number of defenses up to protect her from experiencing the pride concurrently with the affirmation, and we do several rounds of defense work before she can take it in. The shifts are incremental. Closely tracking the client at each step and metaprocessing her experience helps us to solidify each shift “little-step-by-little-step” (Fosha, 2000b, p. 37), or little-bite-by-little-bite. When she ultimately does take in my acknowledgment, a felt sense of connection emerges, followed by sadness for what she has not had, known in AEDP as “mourning the self.” After making some room for the sadness, she is able reflect on her defenses with compassion for how they have protected her.
TH: Mm-hm. Mm-hm. And wow, what a testament to you that you can show up, and, you know, know it’s gonna be hard, so you send a text message, and you show up and say, “This really hurt me.” [explicit affirmation of how the client has taken care of herself]
CL: Well it was really helpful that I told you, as a goal like that. [defense against therapist’s affirmation and recognition]
TH: Mm-hm, but it’s also not the first time. It’s not the first time that you’ve really taken initiative on your own behalf. [continuing to affirm, encouraging the client to take this in]
CL: Well I think it’s better to, like, endure that, like, little uncomfortable conversation than have, like, an uncomfortable relationship. [defense – deflecting again]
CL: It’s not like I would never see her again, ’cause, like, I see her all the time.
TH: Right. Is it hard for you to take in what I’m saying? [making the implicit explicit]
CL: (Smiles.) Yeah. (Client and therapist chuckle.) [mutual recognition of defense]
TH: (Laughs.) Uh-huh, so what’s going on right now? ‘Cause then I see this big smile on your face. [closely tracking body language; making the explicit experiential]
CL: Yeah. I mean, I’m taking it in, it’s just hard for me to, like… give you cues that I am.
TH: Okay, so what happens internally? You hear me say this, it’s really a testament to you, you’re showing up, you’re saying what’s wrong… [slowing down, closely tracking internal reaction to the therapist’s affirmation]
CL: My automatic reflex is like, “Aaaah…” (pushing away gesture with both hands) [Client is articulating anxiety.]
TH: Yeah, you do this (imitates gesture). If you put a few words on this, what’s this? [tracking and mirroring nonverbals]
CL: This is me, like, not being able to take a compliment ever.
TH: Mmhm, so when you do this, what is happening inside? [continuing to keep it experience-near]
CL: Just like… I don’t even want it to come in, I don’t even, like, want it… to let it…
TH: …’cause if you let it…
CL: If I let it… I don’t know, I wouldn’t know how to process it. I’d, like… I’m very cynical when people give me compliments.
TH: Mhm. Mhm.
CL: It’s like, “what do you want?”
TH: Uh-huh, okay….But if you really let yourself look at me now… You know? When I say, “You’re really showing up, it’s so wonderful to see. It really takes a lot of strength, and that’s a real testament to you.” [privileging the new experience, rather than exploring past relationships; disconfirming projections by asking the client to look at me]
CL: (pauses, seems uneasy.) Thank you. (smiles but still looks uneasy and fidgets with hands clasped together in lap.)
TH: Mm. What’s happening now? [moment-to-moment tracking]
CL: (smiles more widely) It’s kinda weird. I don’t know, maybe if I just, like, go through the motions of saying “thank you,” instead of like pushing away, then I’ll learn how to… [Weird is a sign that the client is traversing the crisis of healing change (Fosha, 2006b). The client is trying to make sense of a new experience of accepting the affirmation, rather than pushing it away.]
TH: Mhm. Well, maybe just — can you stay with “weird” for a sec? Just try to sit with that feeling and see what happens. [focusing in on the new]
CL: I get tense. [anxiety]
TH: Uhuh, okay. Mhm.
CL: I think people don’t, like, aren’t… like, people aren’t straightforward, like, you can usually pick it up when someone’s just saying something… like, that’s not what I’m picking up, I think it’s… in here. (gestures to head with both hands.) [Client is aware that she has internalized previous patterns of relating.]
TH: Mhm. Right, so there’s a way in which you’re not really able to sort of take it in from me, there’s a tape already playing in there… [therapist platforming; making explicit her internal working model (Bowlby, 1980)]
CL: Yeah. Exactly.
TH: Uh-huh. What if we did try to…open the doors a little bit, like… just… allow this in, what I’m saying…? [leaning in to the new again, wanting her to take in the affirmation]
CL: Well I think it’s like… I think, like, girls have problems — ’cause, let’s say, like, you tell someone, like, “you’re so pretty” and they say “I know, ” all of a sudden it’s, like, so rude. [defense]
TH: ‘Cause really, what would happen if you allowed yourself to take it in? [pressuring with empathy (Russell, 2004), continuing to lean into the new]
CL: (smiles.) I’d just feel good.
TH: Mm-hm. Yeah, what would it be like to feel good? [using the imaginal channel (Mars, 2011) to help the client ground herself in this experience]
CL: It’d just be like, “oh wow,” like, “it’s good someone noticed.”
CL: It’s good to have that acknowledgement, ’cause it is really hard.
TH: Mhm. It’s really hard…. So I wonder if we can make a little bit of space for feeling good about this conversation you had. (Client nods.) Both having the conversation, and my acknowledgement of it.
CL: I definitely feel good about it, but I guess, like, where the, like, blockage is is your acknowledgement of my part. [Client focuses the work in the relational realm.]
TH: Mhm. Mhm.
CL: It’s not just a thing, as in, an outcome of my efforts.
TH: Right. So tell me more, if we really slow it down. What happens when I acknowledge it? [slowing down, getting closer]
CL: (pause.) I, like, automatically try to think of something to say to minimize it.
CL: That’s, like, what happens in my head right away.
TH: Mhm, okay, so there’s a part of you that comes in to get rid of it.
TH: Are there any other parts?
CL: (Pause.) It’s probably that, like, no, like, it’s like, (nods) yeah, it’s… “thank you.” (We laugh.) [The client finally lands with the affirmation.]
TH: Tell me about that part. [privileging the new and transformational experience]
CL: That part’s like, (smiles, nods) “yeah!” Like, it’s just good to be appreciated, ’cause that was hard…
TH: Mhm. And what a great smile, just a minute ago, as you said that… [continuing to track body language and notice glimmers of transformance]
CL: (pause, smiles widely.)
TH: (chuckles.) What’s your reaction to that? [metaprocessing the therapist’s comment]
CL: (smiling, spreads hands apart in the air and brings them down to her lap.) Just… trying to take it in. [physically indicating that she’s making room]
TH: Uhuh! Uhuh. Yeah. (Client laughs.) I love the smile, I really love it, it’s so great. [delighting in the client]
CL: (smiling, laughing, raises hands.) I don’t know what to do, like… I don’t know. [some anxiety and tremulousness]
TH: Don’t do anything, just feel.
CL: (smiling.) Yeah… Thank you.
TH: You’re welcome, and how does it feel to take it in? [another round of metaprocessing]
CL: It’s good.
TH: Mhm. If you… put a few more words on “good”…
CL: (pause.) Makes me feel very connected to you.
TH: Mmm. Mhm. Yeah. What’s that like, inside?
CL: It’s comforting. It’s nice. (nods)
TH: Mhm. Mhm. I feel very connected to you, too. (pause) What’s it like to hear that? [self-disclosure in the interest of accompanying the client- and I do feel it too! – followed by metaprocessing]
CL: It’s really nice. (nods.) That I can say something like that, and… it’s not scary.
TH: Mhm. Mhm. (pause.) And what’s happening right now?
CL: I, like, feel like I’m gonna cry. (shakes head, laughs.) I don’t know why. [The experience of being recognized and seen by a trusted other can also activate sadness for what the client has not had, known in AEDP as “mourning the self.”]
TH: Uhuh, just… if you just let it come. (pause, client’s face is neutral, tears up very slightly) A lot of feeling about that.
(Client shifts away and starts talking critically about herself in relation to a man she is seeing.)
TH: Mhm. Mhm. So can we come back for a second? ‘Cause I feel like you just shifted into being critical of yourself. [trying to return to the target of feeling connected on the heels of being able to take in the therapist’s affirmation]
TH: And I wonder if you can just come back to feeling connected, ’cause you’re able to say what you need to say, and hear me, and that makes us both feel more connected to one another. If you lean into that experience for a minute, I know maybe it’s hard. I wonder what that’s like. [exploring her internal experience of feeling connected]
CL: This is like, what I want interactions with people to be like. No, like, boundaries (waves hand around), no… secrets, no… no…
TH: Not so much hiding.
CL: Yeah, not feeling like I have to be a certain way, or fill a certain role, or say certain things.
TH: Yeah, yeah. Yeah. (pause, client tears up a bit.) Mhm. So, again, kinda, what’s it like inside, in this moment?
CL: I’m feeling a little sad that, like, I don’t have this a lot. [Fully taking in and metaprocessing the affirmation gives rise to feeling connected, which in turn activates sadness for what she has not had in previous relationships.]
TH: Mhm. Mhm. Mhm. So let’s make some room for the sadness, ’cause I think that’s important too.
CL: I know that that’s good, and like, that’s, like, a step forward to just sit here and feel sad… but I feel myself, like, resisting that…. Like, I’m just trying to get philosophical about it and I’m not letting myself do it.
TH: Yeah, let’s put that to the side, if you can. Because you’re saying, you know, in this context, at least, that there’s a real sadness about not having had relationships where you just felt like you could be vulnerable and connected and honest and show up. And that’s a part of your experience that I think you’ve been trying to… rationalize or intellectualize or get away from, and I just think it’s so important to allow yourself to feel it. [asking parts to stay to the side so that we can stay with the new experience]
CL: It’s just like… (palms up.) This is how it is, and it sucks, like….’Cause, like, I look around at people and I’m like… like, do they just think… like, is it just me? Like, is it just in my head that I feel so distant from anyone? Like, if I felt close to everyone, like if I — I don’t know, there’s like a blockage that I have.
TH: I feel like you find every way to try to blame yourself. [making the defense explicit]
CL: Okay. (Smiles, we laugh.)
TH: Okay, yeah, what’s your reaction to that?
CL: I guess, yeah, I don’t know, um, not like it’s my fault, but this is a ‘me’ thing. (Smiles.) I don’t know, I guess it’s the same thing. (We laugh.) [recognition of how she is using self-criticism as a defense]
TH: So what’s your reaction? You know, and you smile… [tracking of non-verbal cues]
CL: It’s good to be called out.
TH: Yeah. Right. I’m calling you out. If you don’t blame yourself…
CL: Yeah, I guess… I never even, like, would categorize it as blaming myself, but once I say it, it’s like, yep, that’s still blaming. [defense recognition]
TH: Mhm, right, yeah.
CL: It’s scary how, like, clever the mind is…. Like, people know things but they, like, their mind doesn’t, like, let them be aware of it. I’m like, that’s crazy.
TH: Mhm. It’s brilliant…. You know, we’re sort of laughing about how hard you are on yourself, but in a way I think it’s been your mind’s way of trying to take care of you. (Pause, client nods slightly, tears up a little bit.) [The client is feeling seen both in how she has been protecting herself and how hard it has been.]
TH: You’re nodding… yeah.
CL: Like, [I’m] becoming aware of, like, the part of myself that’s just trying to take care of myself. [seeing and having compassion for oneself on the heels of being seen]
TH: Mhm. Say more about that.
CL: I just see a lot of things I do… and I’m like, instead of like, berating myself, I’m like, just trying to be like, “Thank you for trying to take care of me, but let’s try something else.”
TH: Mmm, mhm. Yeah. And what’s it like to do that? [metaprocessing the new experience of being compassionate towards herself]
CL: It’s definitely, like, different, and, you know, I feel like, it’s like weird new territory that, like, the different parts of my mind don’t know how to navigate. [The client is a bit dysregulated as she is traversing the crisis of healing change (Fosha, 2006b).]
TH: Mhm. Mhm.
CL: It’s like… doing the same thing but, like, experiencing it differently. [In this revised narrative she now has more compassion for herself.]
Honing in on the positive, new experience of the affirmation while being held in the relationship with the therapist enables the client to have an experience of feeling seen and connected that allows her to see herself and her defenses in a different, more compassionate manner. The metaprocessing of these positive feelings brings about the realization that hiding and being self-critical, both behaviors intimately tied to the eating disorder, are not her only options.
Filling Up on the Good Stuff: Creating Secure Internal Attachment
Like most symptoms that bring clients to treatment, eating disorders develop out of an adaptive attempt to cope with difficult or otherwise overwhelming experiences. These behaviors, though obviously dangerous and self-destructive to the onlooker, are inherently self-protective in nature. Designed to reduce emotional vulnerability and provide a sense of internal stability, the disorder serves to help the client create distance from more vulnerable internal parts that may be holding painful feelings or memories (Schwartz et al, 2009). Not surprisingly, clients with eating disorders often have high levels of dissociation (Farber, 2008; Schneer, 2002; Zerbe, 1995) and, frequently report disdain for these more vulnerable, often younger, parts of themselves. Helping the client to repair this intra-relational rupture and have empathy for the parts of herself that felt the need for protection is vital in the establishment of secure internal attachment.
The following is a transcript of a session with a 22-year-old client with a long history of bulimia. We are working on gaining access to, and being receptive to, a scared, “needy” part of her without the burden of shame that has previously been present. Through an intra-relational portrayal (Lamagna & Gleiser, 2007), the client is able to treat this younger part of her with generosity and compassion, replacing the internal part of herself that has been dictatorial with a more generous, empathic present-day version of herself. By closely tracking affect, body language, and shifts in how the client is relating to herself, we are experientially building secure internal attachment and grounding the experience in her body. The client spontaneously uses the language of food and the body (“I feel full”) to describe her transformation. Through multiple rounds of metaprocessing of the new relational and somatic experience, she comes to a revised narrative of herself and her history where she feels stronger and capable of holding all internal parts without judgment. Her words “I feel like I can be a mother to myself” are apt and deeply moving to both the client and therapist.
CL: I’m afraid… (shakes head, shrugs, looking down.) … I feel very, very scared.
TH: Mmm. And if you could hear that… young part of you saying that, what would you say or do? [beginning of intra-relational portrayal; trying to get her adult self online]
CL: (pause. tears) I feel like… something needs to be done, and I don’t know if I have the words for the feeling, but something needs to be done to like, take away responsibility…
TH: Mmm. Take some of the weight off of her shoulders. [therapist using the language of food and weight to resonate with the client’s experience]
CL: (nods.) Yeah….
TH: So is there a way? Can we help take the weight off of her?
CL: (nods. crying) Yeah, I’d like to.
TH: Yeah, what would you like to do?
CL: (wipes tears) Um… (chuckles) I’d like to give me my own toys.
TH: Mhm. Okay. Which toys?
CL: (through tear.) I think things that weren’t somebody else’s… [Client has multiple siblings and has talked about the pain associated with only getting hand-me-downs throughout her childhood.]
TH: So if you imagined… giving this part of you something new… [therapist continuing to lead client to have her adult self interact with this younger part of her]
CL: (gets tissue. smiles.) Oh my god, I wanted like, a pink… Barbie powerwheels jeep so bad when I was little…
TH: Uhuh. (We laugh.) So imagine, right, wrapping that up and giving it to her…
CL: (chuckles) Like, I hear that sound. That powerwheels sound….. Fun and free and…
that would be mine and…like, only I could fit in it, and…
TH: Mhm. Mhm. For you, yeah. (Client nods.) So can you imagine that part of you opening up this enormous box?
CL: (laughs) Yeah. (nods)
TH: Tell me, what do you see or hear…? [using the senses to fill out the experience]
CL: (pause.) That rip and that pop of cardboard. Like, the rip of paper, and that pop open from tape on cardboard.
TH: Mhm. Mhm.
CL: And almost, like, no one is there, like, maybe people are there, but… the responsibility of smiling or hugging somebody after they give me a gift doesn’t feel like it’s there, and, like, I could play with it right away and not have to open anything else, and… could leave. [The client is articulating being free of others’ expectations and needs that previously have eclipsed her own.]
TH: (playfully) Yeah. Drive away in your new jeep.
CL: (laughs.) Yeah. Oh man.
TH: So how does it feel to put yourself there with the cardboard, and…?
CL: It’s a similar feeling, I think, of… part of me, like, wanting that aloneness and that freedom and autonomy, but… it not being forced, and not being some kind of reconciliation of like, this is the way I survive…but of like, freedom, and… like, I think I mentioned that before, of like, being alone being a good thing, but… it’s very… it’s very new. [She is alone, but it is chosen, the opposite of “unwilled, unwanted, dreaded aloneness” (Fosha, 2000b, p. 30) that she experienced previously.]
TH: So can you allow yourself to take in this thing that’s yours? You don’t have to be obligated to say thank you, or hug, or clean up the wrapping paper…
CL: (chuckles) Yeah, there is a feeling of just being able to… (laughs) drive away! You know, drive off into the sunset. I get really happy, like, I feel very free, and like, energy in my legs, and, like, parts of my body that like, get up and go. [physical activation signals core emotion]
TH: Right now you feel that.
CL: Yeah, it feels really alive….
TH: So what has it been like to really give it to yourself? [privileging the positive, metaprocessing the new experience of internal attachment]
CL: Playful but rewarding, fun. It’s been, um… a very, like, sensory… like, I can hear it, I can feel that, and… I didn’t really have to think about it too much, it was there….I feel like my child is very… very close, like I can tap into that very quickly. The good and—not like the good and the bad, but like the… the joy and the pain… [The joy and the pain are side by side as we work with this younger part of herself.]
CL: The pain really scares me because there’s so much fear… and I feel really tentative to go there, like… and I feel like when I do go there, like, most often times it’s an explosion.
CL: Um… But, kind of feeling through that today, and then being able to also get in touch with the joy… makes me want to embrace that, makes me want to… like, I feel a little less timid about… the pain, and… (nods)
TH: Mmm. Yes, tell me about that. [helping the client lean into the new experience of not feeling timid about her pain]
CL: That… I guess like also that was like not the only thing about my childhood… but there’s this part of me…that can intervene and give myself a gift, or… pay attention in a way like I haven’t before… [that I] really fought to ignore, to quiet… [new experience of intervening on her own behalf]
TH: Yeah. And that if you can be responsive and gentle and kind to that part of you, right, maybe the scary stuff doesn’t have to be as scary.
CL: Yeah. (nods)
TH: And you’re not really alone, ‘cause you have you to take care of you.
TH: How are you feeling?
CL: It feels like a very, um… I mean, it makes me feel very full. [spontaneous use of food words, a sign that we are on the right track]
TH: Mhm. And what’s that like inside? [exploring emotion and physical sensation associated with fullness]
CL: (looks down, pause) I feel like I can like be a mother to myself. Like, I can… I think I can do that… [The client is able to take in the good. Feeling full makes her feel like a mother to herself, as opposed to wanting to purge until she is empty.]
TH: Mhm. I love that, be a mother to myself. [delighting in the client and affirming this feeling]
CL: (nods) Yeah.
TH: I’m so glad. It’s so beautiful, really.
CL: I feel just very… I don’t know, like I want that, too. It doesn’t feel like disciplinary; it doesn’t get in the way.
CL: It just feels very joyful.
TH: Mmm. And what does joy feel like physically? [grounding joyful experience in the body]
CL: (deep breath, pause) Warm. (nods) Kinda shameless.
TH: Mmm. Wow.
CL: (deep exhale) ‘Cause I feel like I’m seeing these parts of myself that I’ve felt a lot of shame about. But being able to say that those are not necessarily things I need to be embarrassed about or feel shame. [new experience of herself]
TH: That, in fact, those are the parts of you that need more love and attention. And so what does it feel like to feel less shame, and have that be quieter right now? [metaprocessing new experience of not feeling shame]
CL: I don’t really want to retreat. (TH: Mhm). I feel like I want to stay more present, and… it feels grounded.
TH: Mhm. So if you do kind of move more into that space, let yourself…
CL: (tears up) I feel like it’s okay.
TH: Mhm. It’s really okay.
CL: Kind of freeing.
TH: (client tearing up) Yeah. There’s a lot of feeling coming up right now.
CL: Yeah. I feel like that responsibility and that weight… is so, so laden with shame, and fear, and to kind of… chip away at that or expose that…It exposes something to where it’s not like just a ghost or black figure…
TH: Mhm. That it’s more complicated, it’s not just… being scared, or… it’s not just what the disciplinary part of you will tell yourself. Right?
CL: (Nods.) Yeah. Feels a lot more… I think the pain is important, and…
TH: Me too.
CL: And I think… well not I think, but like I feel really… like I don’t wanna ignore that or feel like… “Oh, I don’t have time to, like, talk about that,” or just, “I don’t wanna talk about this anymore…” [referencing avoidance in the past]
TH: Yes. Yeah. So let’s not do that. (pause) How has this been today to do this piece? [metaprocessing]
TH: Yeah, tell me.
CL: It’s… it’s a lot, it’s a… it’s a big part of me that I feel like, when I tap into it, like, (sitting up straight) I almost like physically feel like I get small. I feel like it’s… very fresh, and… it’s a huge vulnerability. [tremulous affects (Fosha, 2006b)]
TH: Mhm. Yeah.
CL: Being small, and being young, and not knowing what to do, and being lonely, makes me feel very vulnerable.
TH: Right. And if you just check in with yourself… how was it to be in that part of yourself today?
CL: I’m kinda happy. (chuckles) [feeling vulnerable, but okay – a new experience!]
CL: ‘Cause that… there’s a part of me that feels like it’s a huge, like… truth nugget, that there’s a lot to that and that… yeah, I think also it’s just not being all sadness, or all joy, like, that they are both there, and letting them be really close together. [Allowing the joy and the pain to coexist, she is no longer needing to split them.]
TH: Right. That it’s not empty or full, right? [using food and weight language to highlight the connection between her experience and symptoms]
CL: (nods) Right. Right. So it feels really… I feel happy… going into that.
TH: Yeah. Yeah. I’m so glad you allowed yourself, and allowed me to be here with you. [making the relationship explicit]
CL: Yeah. (nods) I really felt like you were here with me, and that was helpful.
TH: Yeah, good, I’m so glad to hear that, thank you for telling me that. [therapist receiving the client’s appreciation]
CL: Yeah. (tears up, buzzer rings, wipes a tear)
TH: Another wave of feeling. [closely tracking affect]
CL: I think it’s just a lot. It’s a lot to work with.
TH: …Just kind of stay with that if you can, it’s a lot.
CL: I feel like this is a person that I have spent so much of my life running away from.
CL: Trying to get away… and… to be able to kind of be there for myself and say, like, it’s okay, and… like, there’s nothing to fear, like there’s nothing to run away from, there’s… this isn’t a monster.
TH: Yeah, yeah.
CL: It’s a kid.
TH: Yeah. It’s a kid. And it’s okay. And you can help her.
CL: (nods) Yeah, and not feel a split. That’s really huge.
TH: Mhm. It’s really huge. And what is it like… inside to not feel a split? [metaprocessing new experience]
CL: I feel more full. I feel… a bit more tingly, like activated. [spontaneously using the language of food and the body]
CL: It feels really good to feel like, that… like, being young isn’t a bad thing. And… being vulnerable isn’t a bad thing. Safety doesn’t come out of being, like, mean or stubborn or cutting something off. [The client has a new perspective on her life and her internal parts: core state.]
TH: Wow. Thank you.
CL: (Nods.) Thank you. I feel… I feel like there’s just… there’s a lot there. The mothering feeling is really big.
CL: Like it feels very… very new and, like, nuanced in that… I don’t feel like I’m outside myself doing it. Like, I still feel like that’s a very, like, internal sensation.
TH: …And what does that feel like internally to take care of yourself? [another round of metaprocessing]
CL: My voice, it feels like me. It doesn’t feel like… somebody else, and I think that’s what’s so huge, is that, like, I… I don’t think I knew how to do that, and… I’ve been struggling to find a way to do that… But I think that tingling and the activity and fullness that I feel in my body is because it’s me. [a new and integrated experience of self]
CL: And it feels like a very organic response.
CL: So I feel like a mom, like I feel like, ready to be a mom to myself. [The client is spontaneously narrating a revision of her internal working model.]
TH: (moved by the client’s words) Oh, I love that. It’s beautiful.[affirming]
CL: (nods) It feels very caring.
CL: (pause) And exciting.
TH: Yeah. So from this place, I hope you can go out into the world.
CL: Yeah. (chuckles)
TH: And be good to yourself. Think about the powerwheels… (We laugh.)
The client’s ability to give her younger self a gift through an intra-relational portrayal brings forth a somatic experience of feeling full and that she can be a mother to herself. In further exploring the emotional correlates of this sense, she is able to tap into joy and an awareness of shamelessness—the latter of which is particularly significant for someone with a longstanding eating disorder. Deepening into these feelings through multiple rounds of metaprocessing gives rise to a sense of freedom, where joy and pain coexist without being split, and a coherent narrative of herself emerges.
Let’s Eat! Modeling Receptivity to Positive Affects
The presence of an attuned and caring other not only creates the safety to allow painful emotions to emerge without overwhelm, but it helps to facilitate the deep experiencing of positive affects as well. Fully processing core emotion gives rise to healing affects associated with feeling helped (Fosha, 2000a; Russell & Fosha, 2008), which often emerge in the expression of “loving gratitude” from the client to the therapist (Hanakawa, 2012). Such a disclosure challenges the receptive capacity of the therapist and many therapists, either by training or instinct, feel more comfortable deflecting this appreciation. Much like a mother modeling healthy eating habits for her child, the therapist’s ability to demonstrate her comfort taking in gratitude from the client is vitally important. For the eating disorder client who struggles with how much to keep inside herself and how much to let out (Schneer, 2002), the ability to share how she is feeling is significant; and to witness that feeling being received by the therapist is a transformative experience unto itself. The therapist’s ability to come forward with openness and acceptance of these offerings provides a corrective emotional experience for the individual who has not felt received by earlier caregivers; it helps the client have an experience of being seen and taken in, and thus, feel more connected to herself and to the therapist.
In the brief transcript that follows, the client and I are in the process of ending our work after nearly four years of weekly, sometimes twice weekly, sessions to address her bulimia. Although in many ways she feels ready to end, the impetus for termination is that I am moving and relocating my practice. In the spirit of AEDP, I seek to be affirming and authentic in receiving her appreciation, as well as generous in self-disclosing her impact on me. Closely tracking and metaprocessing her internal process as well as what is emerging between the two of us, the client experiences a sense of safety and connectedness that she can hold on to side by side with her own feeling of sadness about me leaving.
CL: (tearfully) I feel like a different person, but myself (takes a big breath).
TH: Wow. I’m so glad to hear you say that. It really touches me. (client nodding as therapist is talking) [therapist authentic self-disclosure of affect]
CL: I didn’t feel like I needed help in the ways that you helped me.
TH: Mmhmm. Mm hmmm.
CL: And I feel really thankful…for you, and for everything you’ve done for me. (big exhale, still nodding) [articulating therapist’s responsiveness to her need]
TH: You’re very welcome. (Client is making strong eye contact.) [receiving client’s gratitude]
CL: I’m just like, I’m different.
TH: Mm hmm. I know you are. I love seeing that. (client nodding, making eye contact) [self-disclosing that I also see the changes and am delighting in them]
CL: Yeah, I feel really different.
TH: And how does it feel to share that with me and see my reaction? [metaprocessing]
CL: Really good (nodding)
TH: Tell me…
CL: I just feel like (pause, nervous laugh), I have a lot of gratitude for you and toward you, and I wondered how I was gonna say that (making good eye contact).
TH: (Client takes deep breath.) And if you just check in with yourself right now. Here you are, you’re telling me, you’ve said it.
CL: I feel safe. I feel you receiving that.
TH: Mm-hmm and how does that feel? [exploring and expanding feeling of safety around being received]
CL: Really good (nodding), I think I feel like… (looking away, nervous laugh) like vulnerable and kinda silly like thinking about like saying something like that… to you because, I don’t know, it’s just a really powerful thing to say. [some anxiety]
TH: Yeah. (slowly, trying to regulate her anxiety) I’m so glad that you were able to. Really. It moves me. It really touches me very deeply to hear how I’ve affected you and I love seeing the ways that you’ve grown and changed in your relationships, and in yourself, and with me. It’s been huge. Really important. Really important and I’m really taking it with me. (Client is making solid eye contact, nodding intermittently.) [I am explicit that I will continue to hold the client in my heart and mind.]
CL: I hope so, yeah….
TH: Mm Hmm yeah. What’s your reaction to that? [metaprocessing therapist’s statement]
CL: … It’s good to hear that, I mean, I feel connected to you with what you’re saying, and not like alone and feeling like a blubbering person over this. I don’t feel like I’m having this experience over here (motions to the side) and it’s unwarranted.
TH: Yeah. I’m right here with you (client nodding). And what has it been like to do this today? [metaprocessing the experience of self-disclosing her gratitude and experiencing the therapist receiving it]
CL: It feels important…I feel like I have tools. I feel like I have support. … and maybe it’s like internalized tools now because it doesn’t even feel like ‘what will I do now.’ (makes mechanical motion with her hands) It doesn’t feel mechanical. [The tools and support feel integrated.]
TH: Right, sort of from the inside out….what is that like physically for you, to feel that way, just in this moment? [asking for somatic experience of having these internalized tools]
CL: (looks up, pauses) Connected.
TH: Mm hmm.
CL: And connective, like.
CL: Like it allows me to like say that, communicate to you what I’m feeling and feel like I’m simultaneously gonna be okay…. [The experience of having the therapist receive her gratitude allows her to feel connected to the therapist and to know that she will be okay.]
TH: You’re feeling connected to yourself and connected to me, and connective. You can reach for me and tell me things and see me taking it in and receive what I’m giving to you. That’s huge. [therapist platforming; highlighting this shift]
CL: Yeah, that’s really effective.
TH: And If you use a non-clinical term (Both laugh). What’s it like just inside? [orienting her to her body, asking for her somatic experience]
CL: (energized) I feel it, I feel really activated. I feel, like, nervous, I feel like making eye contact, and saying things and receiving them. (makes mutually influential motion with hands) It’s a lot… like a communion [transitional affects]
TH: Yes, yes, I love that word. Yes.
CL: And it’s really hard to do.
TH: I know. And how does it feel?
CL (good eye contact) It feels warm and I feel connected to you, I feel the loss of losing you, but I feel connected and like both of those things feel okay. [The client can hold both the loss of losing the therapist and the connection: core state.]
In the process of saying goodbye, the client has a new experience of attachment. She is both able to share the impact I have had on her and witness and take in her impact on me. My ability to receive her gratitude enables her to retain her feeling of loss while staying connected to me. In contrast to previous relationships with caregivers, she does not need to choose between her experience and the relationship.
Interventions that help clients expand their capacity to receive and hold on to positive affective and relational experiences in session both build secure attachment in the therapeutic dyad and help to revise the internal working models that supported the development and persistence of the eating disorder. Amplifying and deepening core experiences of both receiving and being received helps clients to have a new experience of being connected that does not require abandonment of other internal parts of themselves. Likewise, if, with the therapist’s help and facilitation, the client can provide this for herself, she can experience a more integrated sense of self. AEDP interventions that focus on slowing down, tuning into somatic experience, and making the implicit dynamics explicit and experiential undo her experience of aloneness and set the stage for a new experience. Moment by moment, bite by bite, the experiencing and dyadic processing of these exchanges helps to create new patterns of living that release the need for the eating disorder as a protective attachment figure.
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 Although eating disorders affect people of all genders, they are most often reported in female-identified individuals; thus, the female gender is used throughout this article.