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Eating Disorders

Healing  Eating Disorders with Psychodrama and Action Methods -Beyond the Silence and the Fury

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Down-to-earth mindfulness: Mindful eating
Active Pause is about the simple, down-to-earth ways in which we step out of "automatic pilot" to be more actively involved in what we do. In other words, we see "mindful" as "engaged" - - the opposite of being disengaged, of doing a task mindlessly.

So, one of the things you will see over time in our newsletter, is people sharing specific approaches and experiences. The key word here is "experience": This is not dogma, this is what people actually do, and how it works for them. This is an invitation for you to experiment with it, and to adapt it to your needs.

In this spirit, Linda Ciotola is sharing the approach to mindful eating that she practices and teaches.

There is an audio conversation with her, together with a printable PDF transcript.



Linda has also prepared a "self coach tool" about mindful eating, also a printable PDF, that you can find at: http://activepause.com/zug/selfcoachtools/Ciotola-Mindful-Eating.pdf

Linda Ciotola is a Certified TEP (trainer-educator-practitioner of psychodrama) and the co-author of a book on healing eating disorders.

Please share your feedback about this, as well as comments and suggestions about Active Pause, as a reply to this email or through the Facebook group: http://facebook.activepause.com


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Eating Disorders: An Overview
Linda Ciotola, M.Ed., CHES (ret.),TEP
Eating disorders result from a complicated interaction of biological, psychological, and social factors. People with eating disorders are intensely preoccupied with food, weight, and appearance, jeopardizing their health and adversely affecting relationships.

Although eating disorders most often affect adolescent females, they can affect children as well as older adults, males as well as females, across racial, ethnic, and socioeconomic lines. Some studies show that as many as 20% of eating disorder patients die as a result of their eating disorder.

Physical complications can affect the heart, blood pressure the gastrointestinal system, teeth and gums, as well as the liver and kidney. Amenorrhea and malnutrition increase the risk of osteoporosis. Impaired concentration and thinking result from biochemical imbalances due to malnutrition, anemia, and fluctuating blood sugars. Compulsive over-eaters often suffer from heart disease, adult on-set diabetes, and other obesity-related health consequences.

While patients may layer clothes to hide the body shape underneath, many malnourished patients experience intense sensitivity to cold and/or heat due to a lowered core body temperature. Headaches, fatigue, weakness, dizziness, fainting, low energy, and decreased resistance to infection are also symptoms. Eating-disordered athletes may experience frequent orthopedic injuries due to compromised bone health and the effect of malnutrition on muscles and connective tissues.

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Diet and Mood
Eating disorders often begin with diet. A person with low self-esteem attempts to feel better by dieting to look slimmer, perhaps in an attempt to conform to the current societal ideal (slender for women; lean and muscular for men). Sometimes dieting gets out of control and the dieter feels that "thin" is never thin enough and continues restricting food intake, firmly convinced that he/she is fat, even at low body weight.

Eating disorders are often an attempt to regulate mood. Ironically, acting on the eating disorder often has the opposite effect. Changes in brain biochemistry can intensify sleep and mood disturbances and appetite by dysregulation. Obsessive thoughts about food, weight, and appearance increase as the eating disorder intensifies. Further, persons with a family history of mood disorders, chemical dependency, and/or eating disorders appear to be a higher risk for the development of eating disorders. These suspected neurotransmitter dysregulations may be treated with anti-depressant and/or other appropriate medications.

Although medications can be helpful, they do have side effects and not all patients can tolerate them. Medications are not a cure because eating disorders result from a combination of bio-psycho-social factors which demand multi-disciplinary treatment. Even circadian and seasonal rhythms can affect brain biochemistry and it is possible that traditional Chinese acupuncture may be helpful in regulating these biochemicals and reducing cravings.


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Behaviors and Characteristics
Many of the following behavioral characteristics have been observed among eating-disorder patients
Dieting, restricting, fasting

Bingeing – a typical binge consists of 3,000 to 10,000 calories being ingested between 20-40 minutes
Purging – by self-induced vomiting, laxative abuse, use of ipecac, diet pills, diuretics, and/or compulsive over-exercise.

Food rituals such as cutting and dicing food into small pieces, arranging food in a particular way on the plate, chewing a certain number of times before swallowing.

  • Collecting recipes, food coupons
  • Obsessing, counting calories, fat grams
  • Cooking and baking for others
  • Discomfort when eating with others
  • Secret hoarding and/or secretive eating of food
  • Shoplifting, petty thievery (often to get food)
  • Fear of inability to stop eating
  • Constant preoccupation with food, weight, body size and shape
  • Layered, loose fitting clothing
  • Excessive activity, restlessness, insomnia, early morning awakening
  • Chemical dependency
  • Promiscuity – a reflection of poor impulse control sometimes seen in bulimic patients
  • Obsessive – compulsive behaviors
  • Isolation
  • Suicide attempt
  • People pleasing behavior, seeking external validation
  • Poor impulse control
  • Intense preoccupation with food, weight, appearance, image
  • Intense fear of becoming "fat"
  • Distorted body image (feeling fat when thin)
  • Perfectionism
  • Low self-esteem
  • Lack of intimacy: issues of trust, honesty, and control
  • Difficulty identifying and expressing feelings (alexthymia)
  • Difficulty asking for help
  • Irritability
  • Difficulty concentrating
  • Anxiety – difficulty handling stress
  • Low frustration tolerance
  • Dichotomous thinking ("all" or "nothing")


Anorexics usually deny having a problem, saying that everything is "under control" and claiming, "You’re only trying to make me fat."

Bulimics and compulsive over-eaters, on the other hand, know their behavior is problematic but feel intense feelings of shame and guilt and may deny the behaviors in an attempt to maintain secrecy.

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A Coping Mechanism
However, getting someone with an eating disorder to treatment is often difficult since persons act upon their eating disorders (restricting, bingeing, purging, etc.) as ways of dealing with emotional distress. Eating disorders are symptoms of underlying emotional distress, a way to numb or distract from underlying painful feelings.

Controlling food intake through eating disordered behavior is a maladaptive coping mechanism. Filling up with food may be an attempt to fill emotional needs.

In addition to individual personality and family dynamics, a correlation between emotional, physical, and sexual abuse and eating disorders has been established. These present a number of issues which must be addressed: fear of foods, body image distortions, problems with relationships, control, and trust, to name a few.

Socio-cultural influences are widespread and pervasive, and present an environment in which a person with low esteem could be encouraged to seek external validation by attempting to conform to unrealistic media images. Persons involved in a sport, art, or profession with emphasis on weight or appearance are a higher risk for development of eating disorders: models, gymnasts, divers, body builders, jockeys, wrestlers, distance runners, and ballet dancers, for example.

A Team Approach to Treatment
Since eating disorders are a complicated interplay of various factors, treatment necessitates a multi-disciplinary team approach: physician, therapist, nutritionist. In addition, expressive arts therapists and exercise specialists can be a valuable part of the treatment team. Clients need individual, group, expressive, cognitive, and family therapy; body image treatment, stress management; nutrition education and counseling and education. Confidential support groups are a helpful adjunct to treatment.

Individuals are encouraged to engage in treatment and to remain in treatment as long as necessary. Relapses are an expected part of recovery and clients are encouraged to ask themselves that’s really bothering them when they feel like re-engaging in eating-disordered behaviors. This allows the relapse to become a learning experience.

Recovery from eating disorders is a long-term process, and while a small portion become chronic and still others struggle with periodic lapses, many persons do recover.Copyright1998
Linda Ciotola, M.Ed., CHES, (ret.), TEP

 

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Frequently Asked Initial Questions about Bodywise

Who has BED?
      Anyone who regularly eats for reasons other than hunger.  The behavior causes
 them emotional and/or physical distress, but they feel powerless to change it. 
Many people with BED have been on lots of diets, or are “yo-yo” dieters.  There
is not a specific amount of food one must eat to be considered a “binge” eater; the
issue is how much emotional discomfort and guilt the overeating causes.

What is the program?
      Bodywise is a recovery program for BED.  An assessment will help determine
what parts of the program will best suit the callers needs.  The parts include
individual and family therapy, groups, nutrition counseling, medical management,
and movement therapy.

What is the program philosophy?
      BED can be treated successfully.  Traditional dieting, however, actually makes
BED worse. People who struggle with this issue need to become aware of WHY
they overeat, and deal with those issues first.  Diets don’t work because they fail
to address the underlying issues associated with compulsive eating.  Bodywise is
designed to address these issues, develop new ways of coping with life, and help
put food back into its proper perspective.

What are the costs of the services?
      The costs of services vary.  Also, Bodywise can accept some types of insurance.
      Please call for details:  888-371-0671.

How fast will I lose weight?
      This depends on a lot of different factors.  Bodywise is designed to help people
achieve their natural body weight, at a pace that will allow for physical and
emotional adjustment to the weight loss.  People regain weight in part because
they lose it too fast.  Bodywise works toward permanent change that is
appropriate for each person’s body, not just fast change.

Is there special food to buy?
      Absolutely not.

How do I get started?
      The first step for most people is an evaluation session to determine if Bodywise is
right for you. 

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Eating Disorders Resource Network

Marie deMarco, M.S., R.D., L.D.
Baltimore, MD
410-665-4656
Medical Nutritional Therapy

Linda M. Grande, LCPC, CCDC
Baltimore, MD
Bell Air, MD
410-367-2950
linda@counselingheals.com
Individual & Group Therapy
Imago Therapy for Couples

Linda Friskey, LCSW-C, CEDS
Columbia, MD
410-799-2982
Licensed Psychotherapist and Certified Eating Disorders Specialist
Treatment for Children, Adolescents and Adults

Joan Lewin, M.A.A.D.T.R.
Baltimore, MD
410-494-8266
410-494-9699
Dance Movement Therapist

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PSYCHODRAMA AND THE TREATMENT OF BULIMIA
Monica Leonie Callahan
This is Chapter 6, pp 101 - 120, in L. M. Hornyak & E. K. Baker (Eds.),
 Experiential Therapies for Eating Disorders. New York: Guilford, 1989.)

Since 1981, I have been exploring ways of using psychodrama as part of individual and group psychotherapy with bulimics in an outpatient setting. Almost all of my clients are women; their ages range from the late teens to the early 50s. Psychotherapy is only one part of the treatment.. I encourage clients, as needed, to consult with a physician, meet with a nutritionist and attend meetings of support groups such as Overeaters Anonymous (OA). I do not require a commitment to specific changes in eating behavior in order to begin treatment; indeed, the ambivalence about such a commitment is often the issue that must be dealt with first.

This chapter introduces the reader to psychodrama. in the treatment of bulimics. "Bulimia" here refers to the DSM-3 (American PsychiatricAssociation, 1980) definition of the disorder, which is less restrictive than the definition of bulimia nervosa in the DSM-3R, (American Psychiatric Association, 1987). In. particular, the women I describe may or may not meet the DSM-III-R criterion of, regularly engaging "in either self-induced vomiting, use of laxatives or diuretics,  strict dieting or fasting, or  vigorous exercise in order-to prevent weight gain."

 Others have written extensive reviews of the literature focusing on: psychodrama (Bischof, 1970; Buchanan, 1984; Haskell, 1975; Kipper, 1986; Z. T. Moreno, 1959; Starr, 1977; Yablonsky, 1976) and. on the treatment of bulimia (Emmett, 1985; Garner & Garfinkel, 1985; Neuman & Halvorson, 1983). A number of authors (Boskind-White & White, 1983; Browning, 1985; Neuman & Halvorson, 1983; Roy-Bryne, Lee-Renner, & Yager, 1984; Shisslak, Schnaps, & Swain, 1986; White & Boskind-White, 1984) refer to action methods, such as role playing; gestalt techniques, and assertiveness training used to treat eating disorder, but none of these applications utilize psychodrama: as a primary methodology.

The chapter begins with an overview of the basic principles, objectives, and techniques of therapeutic psychodrama. I discuss how psychodrama is best applied to the treatment of people with bulimia and then demonstrate the use of these techniques to address four central clinical issues. For each issue, I present a psychodramatic group exercise and a reconstruction of a full-blown psychodrama pertaining to that theme. A general discussion follows.

Psychodrama

Psychodrama is a form of therapy and education that uses a wide range of action methods to examine subjective experience and to promote constructive change through the development of new perceptions, behaviors, and connections with others. Participants enact past situations, present dilemmas, future expectations, dreams, fantasies, emotions, and ideas—all occurring in the "here and now" of a special sort of heightened reality. It is the job of the "director"/therapist to help create an atmosphere conducive to such experiences and to develop therapeutic action structures jointly with the "protagonist," or central character, and with the members of the group. (Psychodrama is usually conducted in groups, but it has been adapted for use with individuals as well (Stein & Callahan, 1982).

Psychodrama was formulated by Jacob L. Moreno (1946, 1953, 1973; Moreno & Moreno, 1959, 1969) during the years 1908-1925 in Vienna and was brought by him to this country in 1925. Over the next half century, Moreno further developed and published his ideas for psychodrama, sociometry, role theory, social systems theory, and group psychotherapy. He also founded a residential center for the practice and training of psychodrama in Beacon, NY.

Moreno was an idealist. Drawing from a background in philosophy and theology, he viewed people as possessing a transcendent ability to create through the workings of an inexhaustible inner energy that he termed "spontaneity." Spontaneity is defined as the ability to generate novel.

Appropriate responses to old situations and effective responses to new ones. Spontaneity is also the ability to infuse the familiar with new life and to live in general with vitality and authenticity. The goal of psychodrama therapy is to remove existing blocks to spontaneity so that the natural

creativity fundamental to psychological health and -growth can flourish. This goal is best accomplished by creating a context that approximates real life and by treating spontaneity as it emerges in observable behavior.

Along with spontaneity and creativity, Moreno emphasized the basic interconnectedness of people; in particular, he stressed their need for one another in order to establish an identity and to lead a meaningful life. He postulated a natural flow of feeling perceptions between people that, when left unencumbered, can greatly enhance spontaneity. This occurs, for example, in the ideal situation of role reversal, when one person is able accurately to grasp on many levels the subjective experiences of the other by putting herself in the other person's place.

Moreno studied spontaneity in its moment-to-moment behavioral manifestations. He believed there is a continuous process of "warming up" or preparing for a particular act or feeling state. People use "starters" to warm themselves up, such as mental images, anticipatory physical movements, or the external aspects of an unfamiliar role. Some starters enhance spontaneity, while others, including addictive substances, only appear to do so; instead, they have destructive effects and prevent the healthy development of "self-starters." An example of the use of such dysfunctional starters is the way some people rely on food to coax themselves through anxiety-producing tasks or to produce desired emotional states. The therapeutic goal would be to help them develop alternative starters for achieving the same outcomes.

Another major component of Moreno's thinking was his conception of roles. Moreno viewed people as natural role players. According to him, the self emerges from a constellation of roles, and the status of an individual's role repertoire—for example, the variety of roles available and whether these roles are congruent with inner experience—is an important indication of psychological health. Roles are formed in an interpersonal context and develop differently depending on how they are reciprocated and influenced by the roles of others. Spontaneity is curtailed when people are locked in a rigid system of roles that won't permit growth or change. Thus, for example, some bulimics become quite adept at role playing in the process of adapting their behavior to accommodate others. But beneath an outer expressiveness and flair for the dramatic, these-women are often cut off from their inner experience and they feel empty and confused.

 Learning new roles occurs in three stages: (1) "role- taking," trying on the externals of a role; (2) "role playing," gaining comfort and- spontaneity in a role, and (3) "role creating," changing a. role: by infusing it with unique, personal elements. The power and effectiveness of psychodrama stems from the fact that roles can be assumed, at: least initially, without being experienced as part of the self. In this way,. role taking and role playing provide- a kind of psychological protection that helps an individual explore- unfamiliar, threatening,. or otherwise unacceptable areas of concern..

Moreno believed that the goal of psychodrama is to achieve a "catharsis of integration" through action experiences in the here and now. This form of catharsis produces change not only through. releasing pent-up anxieties and emotions, but also by bringing about new perceptions and, at least potentially, a. reorganization of the self. In the words of Z. T. Moreno (1971), "The greatest depth of catharsis comes . . . from embodying those dimensions, roles, and interactions which life has not, cannot, and probably never will permit."

In J. L. Moreno's view, catharsis does not attain its full therapeutic impact unless it occurs in an interpersonal context. The importance of connectedness with others underlies the three-part structure of a traditional psychodrama session in which the enactment is sandwiched between the "warm-up" and "sharing" phases. During the initial warm-up, central themes emerge and the group develops the underpinnings of trust and mutual involvement needed to support the "action" phase. Following the action, in the sharing phase, the protagonist is reintegrated into the group as members speak in turn of their identification with the psychodrama. This phase may also be a time for "de-roling" (helping people relinquish particularly compelling roles), for, giving feedback to the protagonist, for making interpretations, and/or for contracting for further work.

Along with producing catharsis, psychodrama may heighten the effects of more general curative factors in group psychotherapy. For example, participating together in the enactment of an individual's drama can be an experience of considerable intimacy, especially when the therapist, role players, and group members are able to accurately sense and portray the protagonist's inner world, follow her lead, and facilitate a spontaneous release of emotion. In this way, psychodrama can enhance the group's function as a "self-object" by providing a special sort of mirroring, as Kohut (1977) described it.

Psychodrama can also be a means of highlighting and working through transferences occurring in the group process. For example, the choice of someone to play a significant role may reveal transferential feelings toward that person and may provide an opportunity to work through those feelings. Transferences and projections that emerge in the group's overall interaction can also be dealt with psych od ramatically. For instance, a particular member may dominate a number of sessions with one emotional crisis after another, drawing forth repeated attempts to help from some members while alienating others. Psychodrama techniques can be used to help the other group members discover the function this person is serving for them, both individually and as a group.

Psychodrama's curative effects depend on how it is used. If the goal is behavioral learning or role training, action can be structured to emphasize the use of modeling, anxiety reduction, behavior rehearsal, feedback, and positive reinforcement. A client might enact a stressful situation known to trigger bingeing and purging and then try out alternative ways to cope with the situation. Alternately, if the goal is bringing into awareness and counteracting destructive internal objects, action can be structured to help the protagonist personify her inner voices, release repressed emotions, and affirm the weakened parts of her self. In bulimia, such self-destructive internal dynamics are often played out in the relationship with food, as in the emotional responses during an episode of bingeing and purging.

Detailed descriptions of the wide array of psychodrama techniques and action structures have been provided elsewhere (Blamer, 1973; Hale, 1981; J. L. Moreno, 1946; Z. T. Moreno, 1965). The following are five basic techniques that appear in the clinical examples. These are simplified definitions, as each technique has many nuances and variations.

The "soliloquy" is a monologue in which the protagonist expresses inner thoughts and feelings as if she is talking to herself, but out loud. This technique may be used to help the protagonist warm up to a situation or to help break through resistances and emotional blocking (see case 1 and 3 later in the chapter).

In "doubling," a group member physically joins the protagonist and attempts to give voice to unexpressed feelings and thoughts as the drama proceeds. The protagonist is given the option of rejecting or accepting and incorporating any expression and action by the double. Doubling may be used to provide support, to elicit emotions, to stimulate thinking, or to offer a gentle sort of confrontation (see case 3 and 4)_

In "role reversal," the protagonist exchanges parts with the person with whom she is interacting in order to perceive the world—and, more importantly, to perceive herself—from the other's point of view (see cases 1, 3, and 4).

In the "mirror" technique, another group member portrays the protagonist and duplicates as accurately as possible- her actions in the previous enactment. This gives the protagonist an opportunity to observe her own verbal and nonverbal behavior and to consider how it affects others (see case 1).

In the "aside," the action is stopped in midstream, and the protagonist is asked to express her feelings and thoughts at that moment. This technique may be used to stimulate insight and the awareness of emotions or to help break through unproductive patterns in the drama (see- case 3).

When I invite someone in my group for bulimics to act as the protagonist in a psychodrama, the response may be great enthusiasm or thinly veiled terror, but it is invariably intense. Reactions often stem from fears of being, forced to reveal a vulnerable inner self that is' felt to be unworthy or to express intense emotions that are experienced as unmanageable.

Psychodrama may seem like an improbable treatment of choice for the bulimic, who isolates- herself from others maintains a tight hold on her emotional life, and, above all, fears a loss of control. The idea of enacting in front of others a behavior that produces so much. shame and self-doubt is almost unthinkable. Furthermore, people with so many negative feelings toward their bodies would-be expected to resist something involving so much movement in proximity to others.

Nevertheless, I have found psychodrama techniques to be highly effective for many bulimic clients, in particular, helping people in their efforts to overcome blocks to emotional experience and to gain access to hidden parts of the self. This is facilitated by the use of multiple nonverbal and imaginal cues that engage participants on many levels simultaneously. Psychodrama also provides opportunities to experience, practice, and strengthen the healthier aspects of the self, and sharing such intense experiences with others can help counteract the isolation so characteristic of people with bulimia.

There are ways of adapting psychodrama techniques to the special needs of the bulimic. Some individuals in the group may only be able to work on their own issues indirectly by playing roles in other people's dramas or by doubling other members. The therapist can make good use of the playfulness of some psychodrama techniques, as in the personification of favorite binge foods. For example, someone could take the role of "ice cream" and interact with various group members as a way of exploring the function ice cream serves for them. With respect to the bulimic's sensitivity about her body, techniques may be altered so that they are less threatening. For example, bulimics can be given the option of sitting rather than standing in a particular exercise, or methods can be used that require only limited movement, such as speaking to an empty chair that represents a person or a part of the self.

Case Studies

The following clinical examples were selected to demonstrate the use of psychodrama to address four major areas in the treatment of bulimia: (1) eating behavior and the relationship to food; (2) body weight and body image; (3) intimacy issues; and (4) self-experience and self-structure. The examples consist of group exercises and reconstructions of psychodramas based on actual sessions.

Eating Behavior and the Relationship to Food

The Clock Exercise : Group members are asked to imagine the face of a clock with specific positions for 12, 3, 6, and 9 o'clock spread out on the floor of the room. They walk silently in a circle, mentally passing through the hours of the silently passing day, and then stop at a time when food typically becomes a problem for them. When everyone has stopped, each person is asked in turn to talk in the present tense about what she is doing, thinking, and feeling. This procedure is repeated several times. Finally, people are asked to focus instead on a time of day when they feel particularly strong emotionally and untroubled about food. Everyone then sits down and discusses the exercise.

The clock exercise can also have a more specific focus, for example, how group members feel about their bodies at different times of day. Along with talking at each stopping place, each person could assume a physical position to express her feeling. The clock exercise often produces material for further exploration during the same or later sessions.

Case 1: Laura's Psychodrama

Laura was a 44-year-old woman, about 80 pounds overweight, who had been through a long series of weight-loss programs; however, she was unable to complete any of them. She was never able to stay slim for very long and attributed this difficulty to problems in her marriage and to feelings about her abusive, alcoholic father. She talked of her fear that if she lost weight she would have to face her husband's lack of physical responsiveness and the overall emptiness in their marriage of 18 years. She also blamed her inability to lose weight on her father, who had called her "fat and ugly" throughout her childhood. He had often accused her of being just like his overweight mother, a mentally ill woman who had neglected and abused him. Laura was in reality a talented and appealing woman, but she suffered from deep feelings of shame, self-doubt, and loneliness. She felt best when she took part in performances at a community theatre, for which she had won some local acclaim.

At the time of her psychodrama, Laura had attended individual ther- apy for a year and a half and she had been in the: group for 9 months- Her initial depression had. subsided, and she had begun to deal with feelings about her family and about her past. She still felt isolated, however, and had not yet made any- real changes in her use of food. She had participated in psychodramas focused on others and had herself worked as protagonist on career and family issues, but she had never before worked directly on her eating behavior. This session was a turning point for Laura, as she herself spoke of it later. Subsequently, she began attending OA and a women's support group ate her church. More significantly, soon after, on her own initiative, she began to experiment with- changing her eating habits by eliminating sugar from her diet. She was able to sustain this for   several months before- a family crisis- necessitated the interruption: of therapy.

During the warm-up, Laura said she felt hopeless about her bingeing, a behavior that usually occurred late at night when her family had gone to sleep and she was finally alone. I suggested that she use this session to take -a look at her experience of that vulnerable time and to try to come up with alternatives to bingeing. The action began with Laura using furniture and other objects to set up her living room and kitchen. As a warm-up to the situation, I asked her to imagine that it was a typical night and soliloquize -about her day.

LAURA: My body feels tired, but my mind is still awake. I spent the whole day-chauffeuring my daughter around and talking to people on the phone about the flea market for the church. Everybody wants me to do things. I should never have volunteered, even though it's once a year. Now it's nice and quiet, and I just want to forget about everything. I feel kind of antsy—I think I'll see what's in the refrigerator.

Laura continued to speak as she went through the motions of searching the refrigerator, sitting down in front of the television with her favorite binge foods, and eating. She performed this scene with less spontaneity than she had shown up to that point, and she seemed embarrassed. With the idea of helping Laura learn to anticipate and interrupt her compulsive behavior, I asked her to select someone to represent herself and replay the whole scene as a kind of mirror. Laura would observe in the role of a wise and compassionate counselor to herself. The woman she chose to portray herself played the scene of bingeing in front of the television very effectively. Using small boxes piled high in her lap to represent the food, she eagerly stuffed cookies, cupcakes, and chocolate into her mouth. I stopped the action and asked Laura as counselor to reflect out loud.

COUNSELOR/LAURA: That's disgusting! You're a fat, lazy pig. Is that all you can do with your time? No wonder you're all by yourself!

Laura had not been able to warm up to the assigned role, scolding and abusing herself instead as she habitually did internally. As a way of providing more guidance, I aligned myself with the counselor and asked her to try to see through Laura's outward behavior to the sensitive person inside and to help her find another way to deal with her feelings. The counselor/Laura then suggested that Laura take a walk in her flower garden, listen to the birds, and write in her journal.

Laura returned to her original role and followed this advice. As she took a walk in her garden, which she described in vivid detail, she spotted a family of birds. She chose someone to play the mother bird, then reversed roles with her and sent a message to Laura, the gist of which was as follows:

BIRD: I am part of nature and I am beautiful, and so are you!

Finally, Laura returned to her own role and listened to the bird repeat her words so that she could feel the full impact of her own message and, it is hoped, begin to internalize it.

Body Weight and Body Image

The Mirror Exercise: Group members stand facing an area of the wall that serves as their imaginary mirror. They are given the option of closing their eyes and are asked to visualize themselves in the mirror. One by one, they describe what they "see" and then address their image. Responses are typically negative descriptions and distortions of their bodies, followed by harsh criticisms and demands for change. Each person then takes one step back and speaks from the role of someone significant in her life who might say or think similar negative things about her.

Following this, each person takes another step back and speaks from the role of someone significant in her life who appreciates and supports her struggle. Finally, everyone takes two steps forward and speaks again as herself to her image in the mirror. What is said this last time usually reflects what was said in the second, more supportive role. Everyone then sits down and talks about the experience.

One variation of this exercise is to ask people to reverse roles with their image after they speak from each assigned role and respond to what was said. This method requires that people face outward; a darkened room or private corner may help them feel less self-conscious.

Case 2: Bonnie's Psychodrama

Bonnie was a 35-year-old woman, about 60 pounds overweight, who had a history of alternate bingeing- and restricting, with wide fluctuations in her weight. Her periods of thinness had been achieved through extreme dieting and compulsive exercise. The last such period had occurred during the early years of her brief marriage to an up-and-coming, status-conscious businessman to whom her appearance was very important. After the first year of marriage, Bonnie began to suspect that her husband was having affairs during business trips, though he repeatedly denied her accusations. When the affairs started to become known around town, she initiated divorce proceedings. A bitter battle ensued. over the division of property, and her husband used Bonnie's occasional bouts of compulsive spending to claim that she had squandered their money. The day after the divorce became final, her husband married an 18-year-old model.

Bonnie spoke of feeling humiliated, but she showed little emotion aside from a disdainful tone of voice. She. talked wistfully about having been thin and attractive but seemed ambivalent about losing weight. She had been divorced for 2 years but hadn't dated at all, though several men had shown interest in her. Bonnie talked very little about her large family, but she did mention how afraid she and her siblings were of her minister father, who had been very strict and protective of the girls.

At the time of this session, Bonnie had been in group therapy for about 4 months; it was close to the end of the time-limited group. My hope -was to help her move closer to resolving her ambivalence about changing her eating behavior by focusing on her weight and its defensive function. The psychodrama could also provide opportunities for her to express her accumulated anger.

I asked Bonnie to choose group members to represent her extra weight and to "physically surround herself with them. She chose six people and had them form a tight ring around her. I asked how she felt. She said, "Very comfortable," and everyone laughed. When asked what or who was outside the circle, she said, "People, especially men who are interested in me, and some people in my family." I asked her to choose someone to represent a hypothetical "interested" man. She took this role first while the person she had chosen stood in her place temporarily. As the man, Bonnie was quite seductive.

MAN: I've been watching you ever since you started working here, and I can't take my eyes off you. Are you busy Saturday night? Or what about the weekend—why don't we go down to the shore? My friend has a beach house, and he's not using it.

Bonnie resumed the role of herself, and the person chosen to play the man repeated these words, adding to them in the spirit of the role. When asked how she was feeling, Bonnie said she felt safe where she was and did not even acknowledge what had just been said. As the man came closer and became more aggressive, she-responded more directly: "Forget it! Leave me alone! Find someone else to take advantage of."

I then asked Bonnie to think of a family member she would place outside the circle, and she chose her sister, who had been her running partner in her latest thin phase. She selected someone to play her sister, but began by portraying the role herself.

SISTER: Look at all that weight you've put on! Honey, just trust me. I'll get you back on a diet, and you'll be skinny in no time. We can run around the track like we used to. And look at your hair—you've really let it go. You've got to stop feeling sorry for yourself!

When Bonnie resumed the role of herself, I had the person playing her sister speak these words and at the same time try to pull her out of the "weight" circle. As Bonnie resisted and moved away from her sister, she asked the circle to come with her, at which the group laughed sympathetically.

This seemed like a good point to turn the focus of the drama to the function of the weight encircling Bonnie. I asked her to reverse roles with someone in the circle and tell "Bonnie" inside the circle what she, as the weight, was doing for her. The other members of the circle would follow her lead. At first Bonnie and the others told the inside "Bonnie" how they protected her from disappointment, from abusive relationships, from sexual exploitation, from her family's high expectations, and from painful emotions in general. Bonnie then returned to the center of the circle and people repeated what had just been said. At this point one member of the circle began to speak of the positive things Bonnie was missing in life by hiding behind her weight.

CIRCLE MEMBER: We keep you from experiencing all of what it is to be alive_ We keep you from knowing the joys of sexuality and a loving relationship. We keep you from letting people know all the good things you have to offer as a person. We keep you numb and preoccupied so that you don't feel the ups and downs, the sorrows and joys that give meaning. to life.
Bonnie was moved to tears and later referred to this message as having been very meaningful and encouraging.

As a form of closure, I asked Bonnie to do something with -her circle. of weight to signify where she stood at that moment. She pushed against the circle (people had locked arms) with some: force but without enough to break through. I encouraged the members of the circle- to let her. easily push her way through, as it seemed important to leave Bonnie with a true sense of her remaining ambivalence:

 

Intimacy Issues         

A Self-Presentation Exercise: In this exercise, group members think of a significant person in their life, past or present, who has had something to do with their relationship to food. One by one, each takes the role of that person and "visits" the group in that role. People are given two options: either they can stand outside the group, warm up to the role, and then enter as the visitor, or they can sit in a chair facing away from the group while preparing for the role and then turn their chair back when they are ready to begin. In the role of the visitor, each person is asked to tell the group about himself or herself and then to talk about the group member he or she is introducing (her actual self). During this time, the therapist may ask questions and may invite group members to do the same. The visitor is then thanked for coming and walks away (or turns the chair back around). The group member becomes herself again and is invited to talk about the experience, including feelings toward the person whose role she played.

This exercise can be altered to define the visiting person more specifically or to include more than one role. For-example, each member could choose someone she believes has been part of her problem with food and then someone who has been helpful with respect to that problem.

Case 3: Donna's Psychodrama

Donna was a 38-year-old low-weight bulimic and the unemployed mother of two teenage children. Her first marriage had ended in divorce after 3 years and she was now "happily" remarried. She had never developed job skills or pursued her career interests as she had married and become pregnant soon after high school and had been supported financially ever since.
Donna had been secretly bingeing and purging since high school, when she had been a beauty queen and quite popular. While suffering inwardly during that time, she had maintained a pleasing and confident manner, especially in social situations with her parents, who were active in politics and highly visible in the community.

Donna spent her days chauffeuring her children, following an intensive regimen of exercise, fixing up her house, cooking elaborate meals, and attending work-related social functions with her husband, a prominent lawyer. Her life felt empty to her and she had no close friends in her area. Donna had been in therapy intermittently for the previous 10 years, but she had been open about her bulimia only during the last 3. She had attended a number of groups for eating disorders but, by her own admission, she had dropped out too soon for them to be of any help to her.

At the time of her psychodrama, Donna had been attending group therapy for 6 months. At the beginning of this session, she expressed feelings of hopelessness about ever being able to stop bingeing and purging. Her husband's attempts to be supportive left her feeling confused and frustrated. I invited her to explore her feelings toward her husband with the idea that these might somehow be connected to her bulimia.

Donna began by portraying a typical scenario preceding a bulimic episode. She had spent hours that day planning and cooking dinner. Now everyone had eaten, and she was in the kitchen cleaning up and picking at the leftover food on the plates. I asked her to soliloquize.

DONNA: Another boring day. I hate this life. Why do I even try to cook something special for him? He takes it for granted. He asks me how things are going with my "problem," but does he really understand? Then again, at least he asks me; he really does make an effort. I shouldn't be so critical. Why am I so worried about what he thinks of me? Why am I so insecure about his feelings toward me—like at those awful parties?

"Those awful parties" were cocktail parties connected with Donna's husband's work. I invited her to show us what happened at a typical party. She chose people to play the roles of her husband, his male colleagues, their wives, and some female colleagues. I also asked her to choose someone to be her double.

The scene began with her husband, played by Donna, talking confidently, while drinking, about his successes at work. He began flirting with one of the women, complimenting her and acting intensely interested in what she was saying. Donna then resumed her own role while the scene was replayed with a group member representing her husband. I stopped the action and asked her for an aside. Donna spoke of feeling older and less attractive than the other women. Her double was much more able than she to express anger about her husband's flirtatious behavior, accusing him of needing to prove that he could still attract women. I asked Donna what it would be like to tell her husband how she felt, and she said she didn't know how to do that without jeopardizing their relationship.

I then invited Donna to use the psychodrama as a chance to try talking with her husband in a new way. In the previous scene she had acted in a subservient manner toward. her husband, so I had her place him standing on a chair looking down.at her in the hope that such exaggeration would help stimulate the expression of her feelings. Donna was better able to express her anger toward her husband with him so obviously "above" her,. and she did so with a chorus of other group members who had all been invited to double her.

DONNA: L hate your flirting! I. don't know why you need to do that. And I hate always being the one to compromise, to make things comfortable for you, to support your career. I have needs too, and I need to take- the time to do some things for myself. I am thinking about going to OA meetings and I may not be at home as much at night. You're going to have to understand. You ask me about my bulimia as if 'you're expecting a quick. solution—like• it's just a. matter of self-control and why do I keep doing- it. if I'm happy with you. Well, there's a lot more involved in my problem, and maybe you don't want to hear about it because you wonder if you have an addiction yourself.

Donna reversed roles with her husband, and the group member playing her husband repeated what she had said. She then returned to her own role and considered out loud how she had sounded and which things she might actually say to her husband. Donna was surprised to hear herself be so confident and expressed relief at having vented her feelings. She decided to talk to her husband about going to meetings and about her bulimia, though she was still unsure about showing her anger.

Donna reported some positive changes in her marriage that she related to this session. With more time, it might have been helpful to explore whether Donna's difficulties with her husband harkened back to problems in earlier relationships; my suspicion was that unresolved issues with her parents, now emerging in her marriage, were somehow connected to her eating disorder.

Self-Experience and Self-Structure

A Self-Projection Exercise:  A chair is put in a central location and group members are asked to use their imagination and place in the chair the part of themselves that is afraid of change and doesn't want to give up the bulimia. One by one, each person is given a chance to enact an inner dialogue with that part of herself, either alone or with the help of another group member. Each member begins by sitting in the empty chair and taking the role of the part of herself that she projected—assuming its body position, thoughts, and feelings—and then soliloquizing. Following that, the therapist guides each person in a series of role reversals between the part in the empty chair and the part of herself that emerges in the original chair. There is some advantage to performing the exercise in dyads, as this gives each person a chance to view and hear the different parts of herself.

This exercise can be used to highlight other inner conflicts as well, depending on how the initially projected part of the self is defined. For example, group members could be asked to begin with the part of themselves that is afraid of close relationships. Another variation is to have each person choose two group members to role play the two sides of the conflict so that she herself can stand back, observe her own struggle, and find a way to intervene.

Case 4: Individual Psychodrama with Fran

Fran was a 26-year-old single woman who had been bulimic for 11 years. She had also had periods of cocaine and alcohol abuse and some stealing to support her addictions. She was close to finishing her master's degree in a helping profession but was not sure whether she wanted to work in that field.

Fran had always occupied a special position in her family. Even after her family knew she was bulimic, she continued to be held up to her sisters as the strong, successful, and thin one. In her early teens, she had served as confidante to her mother, who was depressed and very unhappy with her marriage. Fran had always desired a better relationship with her father, who was a workaholic, critical toward himself and others, and emotionally distant.

Fran's family, though living far away, continued to be involved in her life through frequent phone calls, packages, and visits. Their style of closeness left little room for individuality, and, as a result, Fran had become an expert at assuming roles to accommodate others. She felt that her family and friends didn't know the "real" Fran, and she herself was unsure of who she was or what she wanted.

Beneath her cheerful and confident exterior, Fran was quite fearful and periodically would be overcome by intense surges of emotion. She had a repetitive: history of self-destructive relationships with men, in which she would feel overpowered and demeaned and, at the same time extremely dependent. It was the turmoil of one such relationship, along with the worsening of her bulimia, that led her to seek treatment.

Fran's psychodrama occurred after 5 months of individual therapy. She had begun to attend OA and to keep a journal, but she had yet to establish control over her bingeing and purging. I had introduced the possibility of using psychodrama techniques at the start of therapy, and we had used them in two previous sessions.

In this session Fran talked about how she walked around most of the time feeling like the devil was perched on her shoulder, watching and commenting upon her every move. She acknowledged that this figure probably represented a part of herself and, that sometimes she felt like two people. I invited her to explore this duality by acting it out. My hope was to strengthen her ability to counteract what seemed to be a highly rejecting and self-destructive inner voice. I asked Fran to stand behind her chair in the role of the devil and talk to "herself' in the-empty chair:

DEVIL: You never do anything right! Sit up straight! All you do is talk, talk, talk, and then you go home and eat, eat, eat. You're disgusting! Serves you right if you gain weight—your stomach looks bigger already. No wonder: you haven't been exercising enough! You're lazy, and I caught you. cheating again with those reports- They're skimpy, and you know you should be much more thorough. And that journal of yours—you should be embarrassed reading that to Dr. Callahan. You don't even write in complete sentences!

Fran then sat in the chair and became the other part of herself, a part that sounded and acted like a lively and rebellious child. To help Fran make the transition, I suggested that she first move around in the role, at which point she got up and paced nervously back and forth. The words soon followed, encouraged by an occasional doubling statement from me.

FRAN: I can't stand this anymore! I can't live up to your standards. Leave me alone! I'm tired of everything I do and say being wrong—why can't I just live my life? I don't care anymore. I'm so tired of everything. Why shouldn't I eat if I want to? [Fran was getting more and more agitated at this point.] I want some ice cream right now, and I hope you're satisfied! I'm going to get two gallons and turn on the television and eat. I'm so mad! I don't know what to do.

Fran reversed roles a few more times, alternating between herself and the devil. At this point, sensing that it would be acceptable to her, I joined in the role playing. I wanted to help Fran develop a more accepting and nurturing attitude toward herself. The belief that her own needs were legitimate would be a first step toward finding constructive ways to meet them. I took the role of the part of herself she had just played and gave her the task of trying to calm "me" down, to reassure me, to help me feel better about myself, and to help me consider the possibility of giving up bingeing and purging.

At first it was difficult for Fran to respond to the role I was playing with anything other than her accustomed self-criticism and punitiveness. I used my role to help her warm up to her assignment by asking for help in various ways and by responding warmly to her positive efforts. Fran eventually became quite confident and calming in this new role, and her remarks suggested the beginnings of a new perspective on herself.

FRAN/ NEW ROLE: You have a right to be angry—the way you never give yourself a break. You don't have to be perfect! You're doing the best you can, especially when you consider all those years you depended on bingeing and vomiting to deal with things. But it's time to stop hurting yourself and to start using the resources you have. It'll be hard but you can do it! Try to do what they're telling you in OA—take 1 day, even 1 minute, at a time and call someone when you you're upset—maybe even find yourself a sponsor. You're important! You're worth it!
The action ended with me reversing roles with Fran and repeating what she had said so she could experience the effect of her words.

It was not long after this session that Fran became much more involved in OA and began to be "abstinent" for several days at a time—the first major step on her road to successful recovery. She often referred back to this psychodrama, in particular when she tried to understand what had precipitated a loss of abstinence.

DISCUSSION

These case studies present a somewhat idealized and oversimplified picture of psychodrama and its application. The sessions from which the examples were drawn evidenced a good match between the client's readiness, the group's receptivity, and the methodology. An effective psychodrama is often the culmination of a series of preparatory individual and/ or group sessions, and a number of sessions following the psychodrama may be needed to integrate its effects with the rest of the protagonist's experience. Closure is particularly important with bulimics, who are prone to dissociation. The intense experience of an emotional psychodrama may be temporarily "forgotten." But if the emotions generated by a psychodrama are not worked through sufficiently during the sharing phase, the resulting emotional tensions may be acted out subsequently in an episode of bingeing and purging.

The portion of the session following a psychodrama is important for other reasons as well. For example, transferences among the group members may be heightened by the enactment and, with the help of some discussion, brought to a new level of awareness. Psychodrama can also have a powerful impact on transference toward the- therapist, especially as the therapist moves in and out of the active role required to direct the. drama. The greater involvement of the therapist in psychodrama, relative to other therapies, may be jarring to some and reassuring to others—in any case, it can provide meaningful data for therapeutic work-

Psychodrama at its best requires more than the skillful use of. techniques. Its effectiveness depends on the clinical sensitivity and maturity of the therapist, on the relationship- between the therapist and client, and, in the case of group therapy, on the evolution of the- group. Such factors can determine whether, for examples, a particular psychodrama is expe~ rienced by the- protagonist as an invasion of privacy or as a freely chosen opportunity to share and explore private experiences. A sense of control is particularly important for bulimics who are beginning to risk the letting go of long-established defenses. The factors mentioned above- can also determine whether- the protagonist experiences the psychodrama as the product of the therapist and/or the group, or whether she feels it to be her own personal, creation. A sense of ownership Bs crucial for bulimics, who are experts at accommodating others at the cost of failing to develop a secure sense of self. In my experience directing bulimics, it is a good idea to check frequently with the protagonist concerning her experience of the psychodrama at that moment and to offer the protagonist as many choices as possible regarding the structure and progress of the action.

Psychodrama is not intended for everyone, and certain techniques should be used with discretion. Not all people, for example, have the capacity to tolerate the features of psychodrama that require a well-developed ability to separate fantasy from reality and to differentiate the self from others. For example, clients with a borderline personality organization may have difficulty distinguishing between a psychodrama experience and reality or maintaining a secure sense of themselves while taking on the role of others. It may be difficult for them to relinquish roles and role perceptions of others following an enactment. Techniques that involve rapidly switching roles, enacting parts of the self, or personifying objects can be confusing and frightening for more disturbed clients. Also, the emotional intensity of techniques such as doubling demands a tolerance for a certain degree of intimacy that some people find overwhelming.

A final note of caution: Psychodrama is a powerful method not only for the client but for the clinician and may heighten the effects of countertransference. For example, the therapist may become narcissistically identified with a particular psychodrama as a production, especially if the protagonist is accommodating and the therapist has unmet needs for creative expression, recognition, or control. Also, in working with bulimics, the therapist directing a psychodrama may experience the client's own perfectionism and performance anxiety.

There are a number of applications of psychodrama other than those described here that are relevant to the treatment of bulimics. For example, psychodrama can be employed effectively in an inpatient setting, where the immediate availability of other staff and other groups may permit more intensive, confrontational psychodramas. Furthermore, psychodrama need not focus solely on the concerns of individuals but can also be used to examine and work through key moments in group development. For example, in a case of frequent absences by an ambivalent group member, other members might be asked in turn to reverse roles with her and then consider how they identify with her and what function she serves for the group. Such absences can stimulate fears of the, group disintegrating, and the group might explore this in a dramatized future scenario or "future projection" (Z. T. Moreno, 1959). Another possibility is the use of sociodrama, which employs psychodrama techniques to examine issues more generally rather than focusing on the specific experiences of individuals. One sociodrama, for example, might explore- societal expectations concerning thinness and their ramifications for bulimics. Group members could take the roles of people, institutions, or other sources of expectations and direct messages to several people representing "all bulimics." The group could then explore in action the effects of these messages and attempt to generate constructive ways of coping with them.

Empirical studies of the clinical effectiveness of psychodrama are limited (Kipper, 1978), and I am not aware of studies focusing specifically on the use of psychodrama with bulimics. Research is needed in particular to address the questions of which bulimic clients benefit most from psychodrama, when psychodrama is contraindicated, and which psychodrama techniques are effective at particular phases of treatment.

In summary, psychodrama techniques, in the hands of a skilled and clinically sensitive therapist, appear to have a great deal to offer the treatment of people with bulimia. Psychodrama works on many levels simultaneously and is able to accommodate diverse theoretical orientations. Thus, as shown in the case studies, psychodrama techniques can be directed toward the goals of both cognitive—behavioral and psychoanalytic approaches—a frequent combination in working with bulimics. Psychodrama, may be particularly useful in helping clients overcome blocks to emotional experience and in helping them work through internal conflicts that help sustain their eating disorders.

REFERENCES

American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author.
American Psychiatric Association (1987). Diagnostic and statistical manual of mental disorders (3rd ed., revised). Washington, DC: Author.
Bischof, L. J. (1970). Interpreting personality theories New York: Harper & Row.
Blatner, A. (1973). Acting-in. New York: Springer.
Boskind-White, M., & White, W. C_ (1983). Bulimarexia: The binge/purge cycle. New- York: W. W. Norton.
Browning, W. N. (1985). Long-term dynamic group therapy with bulimic patients: A clinical discussion. In S. W. Emmett (Ed.), Theory and treatment of anorexia nervosa and bulimia (pp. 141-153). New York: BrunnerlMazel.
Buchanan, D. R. (1984). Psychodrama. In T. B. Karasu (Ed.), The psychosocial therapies, Part II of the psychiatric therapies (pp, 783-798). Washington, DC: American Psychiatric Association.
Emmett, S.W. (Ed.) (1985).Theatre? treatmmt of anorexia nervosa and bulimia. New York: Brunner/Mazel.
Garner, D. & Garfinkel, P. E. (Eds.). (1985). Handbook of and. bulimia. New York: Guilford Press.
Hale, A. E. (1981). Conducting- clinical sociometric explorations: A manual for and sociometrists. Roanoke, VA. Author.
Haskell, M. R. (1975).. Socioanalysis: Self-direction via-sociometry and           psychodrama.  Long Beach: sociometry and psychodrama CA: Role Training, Associates of California.
Kipper, D. A_ (1978). Trends in. the research on. the effectiveness of psychodrama: Retro-
spect and prospect. Group Psychotherapy Psychodrama and Sociometry, 31, 5 - 17.
Kipper, D. A. (1986). Psychotherapy through clinical role playing. New- York Brunner/Mazel. Kohut, H. (1977). The restoration or the self. New York: International Universities Press.
Moreno, J.L. (1946). Psychodrama (Vol. 1). New York: Beacon House.
Moreno, J. L. (1953). Who shall survive? New York: Beacon House.
Moreno, J. L..(1973). Theatre of spontaneity. New York- Beacon House.
Moreno, J. L., & Moreno, Z. T. (1959). Psychodrama (Vol. 2). New York: Beacon House. Moreno, J. L.' Moreno, Z. T. (1969). Psychodrama (Vol. 3). New York: Beacon House.
Moreno, Z. T.  A survey of psychodramatic techniques. Group Psychotherapy, 12, 5–
Moreno, Z T. (1965). Psychodramatic rules, techniques and adjunctive methods. Group Psychotherapy, 18, 73-86
 Z. T. (1971). Beyond Aristotle, Breuer and Freud: Moreno's-contribution to the concept-.of catharsis. Group Psychotherapy and Psychodrama, 24, 34-43.
Neuman, P. A., & Halvorson, P. A.(1983). Anorexia nervosa and bulimia: A handbook for counselors and therapists. New York: Van NostrandReinhold.
Roy-Bryne, P., Lee-Benner, K., & Yager, J. (1984). Group therapy for bulimia: A year's experience. International Journal of Eating Disorders, 3, 97-116.
Shisslak, C. M., Schnaps, L., & Swain, B. (1986). Interactional group therapy for anorexic and bulimic women. Psychotherapy, 23,'598-606
Starr, A. (1977). Rehearsal for living. Psychodrama. Chicago: Nelson Hall.
Stein, M. B., & Callahan, M. L. (1982). The use of psychodrama in individual psychotherapy. Journal of Group Psychotherapy, Psychodrama. and Sociometry, 35, 118-129.
White, W. C., & Boskind-White, M. (1984). Experiential-behavioral treatment program for
            bulimarexic women. In R. C. Hawkins, W. G. Fremouw, & P. F. Clement (Eds.), The
binge-purge syndrome: Diagnosis, treatment, and research (pp. 77-103). New York: Springer.
Yablonsky, L. (1976). Psychodrama: Resolving emotional problems through role playing. New York: Basic Books.

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FAMILY SCULPTURE IN PSYCHODRAMA: A REPORT*
* This report was written by the protagonist of the psychodrama described below, who preferred to remain anonymous. Edited slightly and posted by Adam Blatner September 4, 2009.


I was 21 when I came to the Menninger Hospital in Houston, Texas around 2003, to be treated for a case of severe anorexia nervosa. I have reconstructed these events from journal notes and a drawing I made on the day they occurred. I have changed all names for confidentiality, including my own name, here calling myself “Ruby.” I came into the hospital from a court-ordered hold at our county mental hospital, considered a danger to myself from my extreme involvement with anorexia and bulimia. I came with no desire to live and no hope to recover from my fight with eating disorders. I came with little hope of ever having a good relationship with my parents, and I was resigned to a life as the "black sheep" of the family. I left with considerably more understanding of myself, my involvement with eating disorders, and my family—much of this due to ideas that began in The Menninger Clinic's psychodrama group.
 
Since it was held on another unit, psychodrama group was a privilege, requiring an attained "level of responsibility." I began to be allowed to go about a month into my nearly four-month stay, though I was required to be accompanied by staff at all times. Psychodrama group was larger than most groups, and maybe because of this the room had an air of recreation. Almost all the patients were glad to be out of a strictly “talking” group. The group was led by Chris, an intern. We started with a “body posture” that represented how we were feeling that day, and then went around the circle describing what our body postures meant. The carefree room quickly began to fill with wisps of fear, anger, and sadness along with the bits of joy. 

Dan's Family Sculpture
In my first group, we were told that we would do a "sculpture." I had no idea what that meant, but some of the veteran group-comers obviously did. A man from the unit named Dan volunteered to be “it.” He was told to pick people from the group to represent different parts of his family, and to place them in the room where they fit, using distance to represent emotional closeness or lack thereof, and body postures to represent their role in his life.  He began.

He picked Ashley, my roommate on eating disorders unit, and me and put both of us side by side in the center, both of us reaching down to Dan, who was in front of us. Ashley was to be accepting, reaching with open arms; I was to be rejecting, holding my palms out and scowling.

Dan continued to select people to represent different individuals in his life, and when he was finished, he was instructed to give each character a line to say. He made his way around the room doing so. Next, Dan had to place himself in his sculpture, and he placed himself on one knee, pleading, in front of Ashley and me. Now everyone in the sculpture was told to say his or her line. Chris rallied us on louder and louder, a cacophony of feelings building on the emotions of everyone in the room.

After a minute or so, Chris stopped us all and asked Dan to go to each person in the sculpture individually and listen to that person say his or her line to him, at which time he was to respond as he wished he could to the “real person.” The two of them then held short conversations guided by Chris.

The Sharing
After that, we went around the entire room and shared how we viewed the experience and what we learned or got out of it. I felt so much emotion after being an actual part of the sculpture, though I could not immediately say what. I felt the swelling of feelings in my chest that happens when I am in true awe of something greater than myself. For me, I noticed how it felt “good” to be in a position of power and control over a man, and physically seeing his emotional response to my bid for that control. I also realized how being in competition with other girls (in this case Ashley) combined with that sense of wanting control makes the use of my body (i.e., through the use of the eating disorder) a very powerful thing. I was amazed after I left at how one hour and one room could so profoundly affect a man; and me. Weren't we just playing a little? I mean, sure it was therapeutic, but I didn't know it was going to really WORK.

Ruby's (My) Sculpture
Psychodrama group progressed each week through different exercises, some more or less profound. I thought from time to time about Dan and his sculpture. One group after we had expressed our body-posture/feeling for the morning, we were told once again that we were going to do a sculpture. Chris asked for a volunteer. I knew I had wanted to do a sculpture since I got to participate in the last one. My hand was up immediately, even before my mind could calculate the consequences; I was chosen. At that moment, things started to turn and flop inside. I was going to put my life here in this room. The instructions were given. I could pick anyone in the room to be each member of my family, and as I picked them I should give them a body posture and facial expression. Physical distance in the room would represent emotional distance in my family. After each person was in place, I would give him or her one line to say to me that would represent our relationship.
 
I began.  I chose “Mom” first and placed her looking half into and half out of the center of the room. “Dad” came next, Dave, because he looked a bit like my dad and he was always joking and teasing the way my dad would be. He and Mom were looking at each other, but were offset, so they didn’t look at each other directly. Dad was to look at me with his forehead wrinkled, disapproving.

Next, I picked Heather for my Aunt Addie. She stood far from my dad (her brother), and was close to where I would later place myself. My dad’s disapproving eyes were turned on her as well, though she looked away from him. Then I picked my Grandma (Dad and Aunt Addie’s mother)—a cute older woman of the same short stature. She stood between my dad and Aunt Addie with one hand reaching to each of them. Her eyes, though, were on me. I picked my cousin Scott, Aunt Addie’s son, and he stood next to my Aunt Addie, but away from the rest of the family, looking away, feeling rejected.

I picked Darcy to be Aunt Kathy (my mom’s sister-in-law). She is on the outside of the circle, closest to my mom. She looks alternately at my mom and me, but turns to reach out to me.

And I also picked Michelle, even though she is not “true” family. She has been a surrogate mother of sorts for years, and I never imagined leaving her out. She stands next to me, on the opposite side of Aunt Addie, the both of them offering their combined support, arms around me.

Finally it was time to pick someone to be me. I picked Aden, also from the eating disorders unit. Though she probably was the closest in looks to me, I picked her out of a more intuitive response. She hung her head and shoulders, withdrawn and scared in part at my direction and in part at her own timidity.


Adding Voice
After everyone in the sculpture had been chosen, it was time to give everyone his or her “line.”
      
My dad said, “You’re not running your life right.” I have often felt his disapproval of seemingly anything I do, and this feeling was reflected in the physical distance between us in the sculpture as well as his disapproving facial expression.
       
Mom said, “I would love you if you were good enough.” My mom is also distant from me in the sculpture, and her body posture (looking half out of the circle) represents an emotional distance. She is interested in knowing me and supporting me but has not often known how to go about making that relationship work. Growing up she was focused some on me, but seemed to be focused more on her non-profit activities.
        
Aunt Addie said, “I love who you are and the woman you are becoming.” Aunt Addie was standing at a distance from dad, as they almost always see things differently, but stood close to me as a source of support and understanding, representing her ongoing emotional support (especially when I felt extremely misunderstood.) She loves me, cares about me deeply, and understands me probably better than anyone in the family.

    
Scott said, “I’m not a part of this family.” Scott has felt much of my family’s disapproval and has grown increasingly emotionally and physically distant. He rarely associates with family other than my Aunt Addie and I.
       
Grandma said, “I LOVE YOU!!” She has one hand reaching to dad and one hand reaching to Aunt Addie, trying to bridge the emotional gap. She tries to make some peace between them but loves them both. Her eyes rest on me, and her love for me is intense.
        
Aunt Kathy said, “I want to know who you really are.” She stands closest to mom because they are the most closely related, but also on the outside of the circle as if she does not want to interfere. She looks between mom and me, but reaches out to me, trying to make a connection. She tries to understand but is not sure what to do or say. She does not want to get in between my conflicts with my mom, but she wants desperately to be closer to me.
         
Michelle said, “You are a person in process!” Michelle is a licensed Marriage and Family Therapist, and this outlook often seeps into our frequent discussions. She is always encouraging me, and her arm around me in the sculpture represents a very deep bond. She is the other person, besides my Aunt Addie, who understands me and holds me up.
       
And finally, I said, “I want to be myself. I need to know who I am.” “My” facial expression and body posture are withdrawn and scared. I felt like this hospitalization was a time when I must start to forge an identity outside of the eating disorder. I felt a strong need to discover myself outside of (and along side of) my parents’ value systems.
        
Chris had everyone say his or her “lines” all at the same time when I said “Action.” I stood in the middle of the group of my family, facing “myself.” Chris kept encouraging everyone, “Louder…louder…” I turned to see different parts of the sculpture, but spent most of my time looking at “me,” head hung and arms folded in. I heard “Dad’s” voice the loudest, telling me over and over that I’m not running my life right. Every now and then I heard my Grandma, quieter and sweet, “I Love You!!!.” I heard the chaos of everyone talking at once and trying to get through to me; to be heard. I covered my face and started to cry but couldn’t. After a bit I uncovered my face. Looking at “me” I noticed that even though Aunt Addie and Michelle were both close and hugging me they couldn’t really “hug me” because my arms were wrapped around me and I was so drawn into myself. It looked more like they were talking in each ear, trying to draw out all of the negative things I was hearing with the positive messages I wasn’t able to tell myself.
     
After what seemed like quite a long while, Chris said, “Stop.” The room fell quickly silent. I looked up.

Chris asked, “What are you feeling right now?”
“Torn……Confused…….”
“I noticed at one point you covered your face. What were you feeling then?”
“Overwhelmed….It all felt so real. The voices I heard loudest were the voices I hear loudest in my life—especially my dad. And I never heard “my” voice.”

Speaking to the Figures
“Okay, now I want you to go around to each person and they will say the line you gave them. Then I want you to respond to that person the way you wish you could, and the two of you may continue to talk. If you are in the sculpture, put yourself in the role of the person you are supposed to represent.”

I was shaking so hard as I began. I went to Grandmother first, because she would be the easiest. She told me how much she had always loved me and always would. I told her how much I loved her and how special she was to me. We talked for a little bit and Chris had us hug. She hugged me just like Grandma would have—so tight, reaching up to say she loved me one more time.
      
I went to Aunt Addie next, and I talked first—I told her how much I was continually strengthened and encouraged by her and how much I loved her. She repeated her line, “I love who you are and the woman you are becoming,” and added, “I am so glad to be close to you so I get to see who you are becoming. I love you so so much.” We talked and hugged.
      
I caught myself going to all the most positive or easy to talk with people first, so I stopped for a second to make sure I had time left in the group to really deal with the harder things.

I went to Mom. She repeated, “I love you, but you’re not good enough.”
      
Chris asked me, “How do you feel when she says that?”
I talked to Mom, pleadingly. “I know that when I hear that, you are saying that you do love me and that you want the best for me. I know you don’t mean those words the way I hear them…”

Chris asked, “How do you feel when you hear that you aren’t good enough?”
“I feel hurt and frustrated…I feel angry.”

Chris said, “Say you’re angry like you mean it.”
“It makes me angry to hear that.”
Chris: “Like you really mean it.”

“It makes me so angry to always hear how I am sick and that I am loved but that I am so sick!”

Chris prompted quietly, “And I wish…”
“And I wish that we could talk to each other without me having to hear all the ways that my mind and my thoughts and the core of who I am is flawed!”
           
Mom said, “Well, I’m just trying to make sure that things turn out good for you. I just want the best for you.”

I don’t know what shifted or how, but it was just like Mom—except in a second we went from bickering to understanding each other. She said that she knew she didn’t always do things great either and that she would try to work on things too—that we would both work together and we would get better at things. In those words, she took a part of the “sickness” as her own, and because my  “real-life” mother has been so adamant that I was the problem, that acceptance made a world of difference. We were suddenly hugging, and in that hug I felt how much my mom really does love me.

I went to dad. He said again, “You’re not running your life right.”
Chris asked me, as he had done with mom, “How do you feel when he says that?”
I was more outgoing with dad. “ I hate to hear that from you! Anything, everything I do is wrong to you!”

Dave used my name to talk to me, “Ruby, I just know I have made so many mistakes and they were hard to learn from. I don’t want you to have to go through all the same things I had to.”

“But Dad, how come nothing is ever okay, nothing I do is right?!?”
“It’s not that it isn’t right, I just see things you could do better sometimes and I want the very best for you.”

“No, nothing is ever right to you!”

“It is, honey, I’m not very good at saying it though. But I am so proud of you. I love you so much. I wish I said things better. I want to protect you and it comes across wrong. I don’t want to control you, I want to protect you.” Tears slid down Dave’s cheeks. We hugged for the longest time and both cried.

Group was almost over, so that was all I had time to do individually. I’m sure Chris went around the room, but I don’t remember it. I stayed to myself while we waited for staff to come take us back to the eating disorders unit. I was still crying, but not hard. I was shocked in a visceral way.

I made my way back to the unit, picked up my journal and went to the gazebo in front of the unit. I cried over Dave, my "sculpture-dad's," sheer concern and love, carefully masked in the sculpture as admonishments. I cried for the holes I wanted to see sewn up, and the people emotionally crashing into one another.

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