Transcript St. Louis Employee Assistance Professionals Association (EAPA)

Treatment of Process Addictions: Sex, Food, Codependency, and Other Forms of Self-Injury
St. Louis Employee Assistance Professionals
Association (EAPA), October 2009
Mark Schwartz, Sc.D.
Castlewood Treatment Center for Eating Disorders
800 Holland Road
636-386-6611
www.castlewoodtc.com
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VIOLENCE TURNED
TOWARD SELF
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How is Recovery Measured
Recovery is not just the absence of symptoms…it is the presence of a full life as evidenced
by the ability to be human. A truly recovered life will reflect spontaneity, freedom, the
ability to breathe, to have wants, needs and desires, knowing that the quest for
perfection is an unattainable illusion. Having the ability to embrace the feminine, having
close intimate relationships, and it is being aware of the tears in your eyes (whether out
of intense or subtle sadness – or out of the joy – or from a flicker of utter gratefulness)
and then to allow your tears to flow freely. It is a life in which decisions and choices are
made more from self and less from a shame and fear based prison. It is a life where you
fully experience pleasure, joy, and passion and believe and know it is good to desire and
enjoy sex…
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Kilpatrick et al.. 1992
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
On March 9th, 1997, the U.S. Department
of Justice released results of a new study
which showed that if our present rates of
incarceration continue, one out of every
twenty babies born in the U.S. today will
spend some part of their adult lives in
State or Federal prisons.
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
California, for example, is now spending
more on its criminal justice system than
on higher education. Though we have
been greatly concerned about the
government spending on the U.S. Health
Care system, which many deem to be in
crisis, we have not noticed that the cost
of the criminal justice system is three
times the cost of the nation’s entire
health care budget.
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
If the current rate continues, according to
the New York Times, the number of
people incarcerated will soon overtake
the number of people attending colleges
and universities in our country. Already,
one in three African-American men in our
country are under the supervision of the
criminal justice system.
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Aleksander I. Solzhenitsyn
If there were evil people somewhere insidiously
committing evil deeds, and it were necessary
only to separate them from the rest of us and
destroy them. But, the line dividing good and
evil cuts through the heart of every human
being, and who is willing to destroy a piece of
his own heart?
-Gulag Archipelago
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DISSOCIATION
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Parts
In response to life experiences, parts can
become extreme and destructive,
obscuring the leadership of the Self.
 People who have undergone severe
trauma typically have more discrete,
polarized parts.

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Parts
Sub-personalities or aspects of our personality
that interact internally in patterns that are
similar to the ways that people interact in
human systems.
 We all have parts: think of your playful part,
your organized part, shy part, etc.
 All parts are valuable and have good intentions.
Even though the behaviors might appear to be
destructive, they are intended to protect the
individual.

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REENACTMENTS
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Self-cutting
To think about my father raping me and his sweat dripping
on my small body only begins to turn me to stone. While all
this happened, I was stone; I was dead; I was gone, yes, gone
far beyond imagination. Far into a world where I walked
around like a ghost. I was in this world where life passed me
by. I only hoped to come out – and come out alive. But, as it
seems, I am alive, and I did come out alive. But my question
is, am I alive, am I living? I feel like I’m not. But the truth is, I
live on other people, I live – depending on other people to
see me to the end. Now, where does that leave me? The
cutting makes me real; it helps me fulfill the need for pain.
Because without pain, I don’t think I would think I was real.”
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Abuse-Related Tension-Reducing Behaviors
(Briere, 1992)



Engages in activities designed to provide one or more of the
following: a) temporary distraction, b) interruption of dissociation
or dysphoric states, c) anesthesia of psychic pain, d) restoration of
control, e) distress-incompatible sensory input, f) temporary filling
of perceived emptiness, g) self-soothing, and h) specific relief from
guilt or self-hatred.
Sense of calm and relief ensues. Subsequent guilt or self-disgust at
having engaged in such activities may also be present along with
sense of not being in control of one’s actions.
Reinforces use of tension-reducing mechanisms in the future:
“Behavior that reduces pain is likely to be repeated in the presence
or threat of further pain.”
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Suicide Dynamics
Adult Children of Incest & Child Abuse
(David Calof, 1989)
1.
2.
3.
4.
5.
6.
Ideation natural and inevitable in recovery process.
No one wants to be dead. They just want to stop
hurting, and work just to be.
Client may use suicide fantasy as the ultimate
permission to engage in therapy.
Homicidal currents/suicidal compliments in polyabusive families.
Child mind lacks ability to think through a trauma. To
them, it will never end.
Taking the secret to the grave. Not telling.
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Suicide Dynamics
Adult Children of Incest & Child Abuse
(David Calof, 1989)
Fear of overwhelming or causing harm to therapist.
8. Intra-psychic homicide/punishment.
9. To punish another – tell me to hurt you (insideoutside boundary indistinction).
10. Don’t deserve to be. World better off without me
(damaged goods framework).
11. Identification with another. Be dead for them.
12. Suicidal modeling in the extended family.
13. To demonstrate ownership of life and body.
14. The illusion of control.
7.
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Compulsive Self-Injury
(Dusty Miller, 1996)


TRS women and men do to their bodies something that
represents what was done to them in childhood…
For women and men who can be understood as
suffering from Trauma Re-enactment Syndrome,
patterns of self-harming behavior tell a story of how the
child learned to be in relationship and learned to be
with (her) self.
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Central Characteristics of Trauma Re-enactment Syndrome
(Dusty Miller, 1996)
1.
2.
3.
4.
The sense of being at war with one’s own body.
Excessive secrecy as a central organizing principle of
life.
Inability to self-protect, often evident in a specific kind
of fragmentation of the self, and
Relationships in which the struggle for control
overshadow all else.
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Compulsions
(Larkin & Whiting, 1991)
“Compulsions serve as clues to the deeper stories of our
lives, and individual’s history of emotional
woundedness.”
A compulsion covers up an interior emptiness. It
indicates the presence of a control mechanism – a way
of escaping something that is ultimately unescapable
and unavoidable.
Compulsions represent attempts to compensate for low
self-esteem and powerlessness.
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Early Maladaptive Schemas
Self-perpetuating
 More resistant to change
 At the core of self-contempt
 Are actively maintained
 Are tied to high levels of affect and
arousal
 Lead to distress

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Repetition
Nevertheless, the need to repeat also has a positive
side. Repetition is the language used by a child who
has remained dumb, his only means of expressing
himself. A dumb child needs a particularly empathic
partner if he is to be understood at all. Speech, on the
other hand, is often used less to express genuine
feelings and thoughts that to hide, veil or deny them
and, thus, to express the false self. And so, there often
are long periods in our work with our patients during
which we are dependent on their compulsion to repeat
- for this repetition is then the only manifestation of
their true self.
- Alice Miller
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Sex Offenders Ascribing to Past Trauma
Barnard, Henkins & Robbins (1993)
Child Sexual Abuse
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71.0%
Physical Assault
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58.0%
Serious Accident
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31.0%
Other Trauma
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29.0%
Rape
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17.0%
Military Combat
4
7.6%
Natural Disaster
1
1.9%
At least one of the
above
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97.0%
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Ethnic Disorder



The disorder is a final common pathway for the expression of a
wide variety of idiosyncratic personal problems and psychological
distress; people who develop the disorder can range from mildly to
severely disturbed.
The disorder is a highly patterned and widely imitated model for
the expression of distress; it is a template of deviance, a “pattern
of misconduct,” providing individuals with an acceptable means of
being irrational, deviant or crazy.
They utilize these cultural preoccupations as defenses that enable
them to escape from - and achieve some sense of control over unmanageable personal distress, most of which revolves around
issues of identity. Again, similar to hysteria, anorexia and bulimia
are socially patterned, the fashionable style of achieving
specialness through deviance.
Richard Gordon, 2000
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SEXUALLY
COMPULSIVE
BEHAVIOR
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Web - General
The number of people in the United States who use the
World Wide Web is estimated at 158.3 million,
averaging six accesses per week, six sites per visit, and
spending an average of three hours and 22 minutes per
week online (Nielsen-Net Ratings, 2001). This translates
into over half of all American households and reflects a
trend that grew by 58% over a 20-month period
(Department of Commerce, 2000). The amount of
information and opportunities is overwhelming, with an
estimated one billion unique web pages available in
January, 2000 (Inktomi, 2000).
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Cybersex

As of January 1999, there were 19,542,710 total unique
visitors/month on the top five pay porn websites, and there
were 98,527,275 total unique visitors/month on the top five
free porn websites.

In November 1999, Nielsen Net Ratings figures showed
12.5M surfers visited porn sites in September from their
homes, a 140% rise in traffic in just six months.

Nearly 17% of internet users have problems with using sex
on the net.

Severe problems with sex on the net exists for 1% of Internet
users, and 40% of these extreme cases are women.
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Cybersex, cont.

Most e-porn traffic, about 70%, occurs weekdays
between 9 a.m. and 5 p.m.

There are 100,000 Websites dedicated to selling sex in
some way; this does not include chat rooms, e-mail or
other forms of sexual contact on the Web.

About 200 sex-related Websites are added each day.

Sex on the Internet constitutes the third largest
economic sector on the Web (software and computers
rank first and second), generating $1 billion annually.

The greatest technological innovations on the Web
were developed by the sex industry (video streaming is
one example).
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Sexual Desire as a Self-Function

Sexual desire in such cases can be largely anxiety driven, as
the desire to conquer the other, or multiple others. In order
to continually feel accepted, the individual is driven to
compulsively seek affirmation of their acceptability as a way
of combating deep self-hatred. Thus, hypersexual individuals
starving for attention, affection, touch or validation, but
without the structural capacities to substantially meet these
needs, can achieve a tenuous, fleeting sense of reassurance
and pseudo-intimacy. Hyposexuality, on the other hand, sets
up a shield to protect the individual from anticipated
rejection and prevent the vulnerability of allowing another
close enough to recognize perceived self-defectiveness.
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EATING DISORDER
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Treatment of ED Premises Philosophically
Different developmental trajectories.
 Symptom has developed as a survival
strategy.
 Symptom is logical, rational and adaptive
 Symptom remission is dependent on
understanding the logical development
and allowing for a more optimal solution.

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The Eating Disorder allows you to bypass,
override and transcend
It puts you in control, binds your anxiety,
makes you invincible and allows you to
serve only one master.
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Eating Disorder Patient’s Experience of Recovery
Ability to take responsibility for self and eschew victim
mentality
 Establishment of a sense of “true self,” “real me,” or
“knowing who I am.”
 Capacity to formulate goals, tolerate setbacks, yet
maintain positive motivation to get better.
 Reclamation of sense of one’s personal power.
 Decreased emphasis on perfectionism.
 Firmer interpersonal boundaries; enhanced capacitates
to set appropriate boundaries.
 Cultivation of sense of purpose, meaning of life.

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Re-framing the Meaning of Symptoms

Start with the assumption that every symptom is a valuable piece of data!

Use psychoeducational material to make educated guesses about the
meaning of symptoms, as a symptoms memory or a valiant attempt to
cope.

Ask her, “How would this ____ have helped you to survive in an unsafe
world?” “Helped you feel less overwhelmed? Less helpless? More
hopeful?”

Look for what the symptom is trying to accomplish: i.e., chronic suicidal
feelings might offer comfort or a “bail-out plan”; cutting might help
modulate arousal; social avoidance could be an attempt to avoid “danger.”

Once it is clear what the symptom is trying to accomplish, then therapist
and patient can look for other ways to accomplish the same goal in a
context that describes the patient as an ingenious and resourceful survivor,
rather than as a damaged victim.
(Fisher, 2001)
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Failed Protectors
Where part got the idea that it had to
coerce and shame her into dieting,
working, being nice – usually a parent
monitoring and scorning – part like a
single parent – those are inner censors
and tyrants that control us, keep our
noses to the grindstone and do not risk
any behavior that brings us the slightest
embarrassment.
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Shame
Feeling of exposure inherent to the
experience that can accompany extreme
amount of utter worthlessness. Feeling
exposed results in the individual critically
scrutinizing the minutest detail,
heightening the awareness of being
looked at and seen. The feeling of
exposure can produce rage.
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RELATIONSHIPS
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Gottman

Of the 35% of couples making initial gains in marital therapy, 30-50% relapsed in two
years. Of couples presenting for marital therapy, 44% divorced within 5 years.

Anger in marital interaction does not predict divorce, whereas contempt and defensiveness
did so reliably.

Conflict avoiding and bickering passionate couples can have stable happy marriages. Still
have romance after 35 years.

Sharing power, accepting the wife’s influence is critically important for stability.

Even the best marriages, marital problems do not get solved at all, they become perpetual
issues. What is important is the affect surrounding the way people talk about perpetual
issues. 69% of the time couples are discussing the perpetual problem.

In failing marriages, people communicate clearly, but what they communicate is negative.

People who have the highest expectations have the best marriage.

The first three minutes of interaction was predictive for 96% of couples of stability. Harsh
astart up by the wife followed by husbands stonewalling (looking away or down, stiffen
neck, controlled facial expressions) was the most lethal prediction. Contempt (statement
and putting self above) are the best predictor of divorce.
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False Self
(From Winnicott)
Parents who are intensively over-involved with
their infant cause the child to develop a false
self based upon compliance. Care-giver doesn’t
validate the child’s developing self, thus leading
to alienation from the core self. Parenting
practices that constitute lack of attunement to
the child’s needs, empathetic failure, lack of
validation, threats of harm or coercion and
enforced compliance, all cause the true self to
go underground.
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Assumptions Regarding Relationships
(Freeman, 1992)

Unfinished business – is a present emotional reaction
shaped by a past experience. It is a reactive response
guided by strong emotional feelings based on past
experience of anxiety. Unfinished business does not
allow for a thoughtful, creative response to a here and
now situation; rather it triggers an emotional reactive
response. Who we bring into our life, our major life
decisions, how we embrace important people and the
amount of closeness and distance we need emotionally
are all shaped by unfinished business carried into adult
life. Relationship problems are more a reflection of
unfinished business than expressions of lack of
commitment, caring and love.
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INTER-PSYCHIC INTIMACY
(between the couple)
vs.
INTRA-PSYCHIC INTIMACY
(within the individual)
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ATTACHMENT
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Disorganized Attachment
The difficulties encountered during the
complex process of social adjustment,
poor flexibility and resilience in facing
life’s painful events, the possibility of
building a sense of self that is coherent
and integrated, of producing a fluid and
coherent narration, ultimately
psychopathological suffering itself, seem
to point to the attachment pattern as an
important aetiopathogenic factor.
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Target Symptoms For “Earned Secure
Attachment”
1.
2.
3.
4.
5.
6.
Turning towards other people for self-soothing
and intimacy.
Establishing a coherent narrative regarding
one’s life.
Establishing metacognitional thinking in
relation to family of origin.
Minimize idealization and family loyalties.
Establishing clarity with regards to self and self
in relation to significant others
Resolution of significant losses in one’s life.
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Metacognitional
Metacognition means treatment of one’s
mental contents as “objects” on which to
reflect, or in other words “thinking about
one’s thinking.” Distinct skills contribute
to its characterization, such as the ability
to reflect on one’s mental states,
elaborating a theory of the other’s mind,
decentralizing, and the sense of mastery
and personal efficacy.
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TRAUMA
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Compassionate Witnessing
This occurs when the Self of the client is able to
witness the stories of parts from a
compassionate position. Ask the client to
identify an activated part (usually associated
with extreme behaviors, thoughts, or feelings).
Ask the client where in the body the part
(position of Self) indicates that another part is
blended with the Self. Ask the blended part to
please step aside and let the Self work with the
activated part (this may include asking more
than one part to step aside).
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Steps in Trauma Resolution
Develop safety and trust.
Establish grounding and containment.
Establish control over out-of-control
behavior.
4. Teach cognitive errors, affect modulation
and life skills.
5. Establish relationship between injured and
executive selves.
6. Allow injured self to “tell,” reassociating
affect, sensation and knowledge.
1.
2.
3.
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Homework Assignment
Cognitive Processing Therapy for Rape Victims
(Resick & Schnicke, 1993)
Assignment #1
Please write at least one page on what it means to you that you were raped. Please consider
the effects the rape has had on your beliefs about yourself, your beliefs about others, and your
beliefs about the world. Also consider the following topics while writing your answer: safety,
trust, power and competence, esteem, and intimacy. Bring this with you to the next session.
Assignment #2
Start over and write the whole incident again at least one more time. If you were unable to
complete the assignment the first time, please write more than last time. Often, the first
version reads like a police report with nothing but facts. Add more sensory details as well as
your thoughts and feelings during the incident. Also, this time, write your current thoughts and
feelings in parentheses (i.e., “I’m feeling very angry”). Remember to read over the new account
at least once before the session. If there was a second incident, please begin writing about that
event.
Assignment #3
Please choose two of your stuck points and answer the questions on the Challenging Questions
Sheet with regards to each of these stuck points. Write your answers on a separate sheet of
paper so that you can keep the list of questions for future reference.
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Three Conditions Necessary for
Information Reprocessing
Therapist activates fear structure by providing
information that matches the information
represented in the structure.
 Information provided during therapy must be
incompatible with pathologic elements in the
structure.
 Trauma memory, including emotional element,
must be repeatedly activated by contact with
trauma-related structure.

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Resistance Group
1.
How am I avoiding remembering?
2.
How am I avoiding feeling?
3.
How am I avoiding talking about it?
4.
How am I minimizing it?
5.
How am I avoiding focusing on enjoying parts of life?
6.
How am I avoiding noticing triggers that cause me to hurt self?
7.
How am I avoiding dealing with current life stresses?
8.
How am I still protecting my family?
9.
How am I avoiding being close to others?
10.
What secrets have I not yet discussed?
11.
How am I fighting my therapist and working my program?
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