Eating Disorder Treatment as a Process of Mind–Body Integration: Special Challenges for Women

The concept of body image remains too focused on internal representation and not enough on internal experiencing. Body image is but one expression of the more foundational body self. When an eating disorder is conceptualized as an attempt to manage an impaired sense of body self (and associated disregulation), the ultimate goal of treatment becomes embodiment. The eating disordered body must be worked with as an actual as well as symbolic body and understood within its own developmental trajectory. The gender-specificity of eating disorders is explored by focusing on three particular bodily challenges for females in our society: (1) Women are more likely than men to unconsciously use their bodies as repositories for their dissociated need and desire, (2) girls’ bodies are mirrored in a more distorted and overstimulating manner than boys’ and (3) because girls are the same biological sex as their usual primary caretakers, they are more likely to be used as narcissistic extensions. A clinical example is presented, illustrating the influence of these female bodily challenges on the development of body self and eating disorders and how these issues play out in treatment. An intensive clinical focus on the patient’s and therapist’s body states allows for the desomatization and integration of dissociated affect, resulting in a more integrated body–mind self and a decreased need for an eating disorder.     

Spontaneous self disclosures in psychotherapy

The closeness and intensity of feeling that develops between therapist and patient raises complex issues related to the therapist's neutrality, the transference, the countertransference, the therapeutic alliance, and the very essence of the curative aspects of the relationship. The issue of the relationship of self disclosure and the evolving transference, countertransference complex is discussed. It is suggested that on some occasions, the pressure a therapist feels to spontaneously disclose something intimately personal is an indication that the therapeutic role has become reversed and the therapist is using the process to heal a vulnerability in himself or herself. The patient unconsciously participates in the interest of safeguarding the treatment process. In such instances the self disclosure need not interfere with the evolving transference. It may lead to great spontaneity in the process and to opening areas of affect previously unreachable. Self disclosures cannot be viewed as technical innovations to avoid stalemates in clinical practice. Rather, they are facts of our clinical life, facts that must be explained and understood rather than judged and condemned.     

The ‘Not to be Opened’ Letter: Family Secrets,Hidden Knowledge and Violate Prohibitions

This paper presents a view of family secrets that is informed by their broader biological and cultural context. Two particular perspectives are employed. First, Bateson's biologically-based concept of ‘sacred knowledge’ is extended to apply to human cultural practices, such as the ban on certain forms of intergenerational instruction. Second, the anthropological concept of ‘taboo’, as expressed in cultural practices, myth and folklore, is used to provide insight into the mixture of awe and disgust which surrounds secrets, and into the possibilities for both positive and negative outcomes when prohibitions are violated. From these complementary viewpoints, the author explores why family secrets arouse such intensely polarised feelings in helping professionals as well as in family members, and suggests more morally neutral frames within which therapists might view secretkeeping behaviour. A case illustration is used to illustrate potential problems with the assumption that secret knowledge should always be shared across generational bound-aries. Finally, the ‘not to be opened’ letter is introduced as a therapeutic option in cases where the clients and/or the therapist are unclear about the wisdom of revealing a particular secret.     

The Impact of Family Therapists’ Adult Attachment Styles on Their Career Choice and Approach to Therapy: An Interpretive Phenomenological Analysis

Attachment theorists have highlighted the role of the therapist in providing a ‘secure base’ for therapy. This raises the question of how therapists with insecure as well as secure attachment styles manage the integration of their personal experience and their therapeutic work. This study explored the relationship between family therapists’ adult attachment styles, influences on their career choice and their approach to therapy. Participants’ (n = 11) attachment styles were previously assessed using the self-report Experiences in Close Relationship questionnaire. Three participants were assessed as having a ‘secure’ attachment style; three were ‘preoccupied’, three ‘fearful’ and two ‘dismissing’. They were interviewed about their practice and the impact of past or current relationships on their development as therapists. Interpretive Phenomenological Analysis was used to analyse the verbatim accounts into cluster of master themes and subthemes. The analysis identified two master themes: understanding one’s self and the impact of family of origin experiences, and the integration between personal experiences and therapeutic work. There were differences in responses relating to the therapists’ attachment styles. Therapists with ‘secure’ adult attachment styles were aware of their challenges and able to utilise their experiences in their practice and respond sensitively to their clients. Conversely, those with ‘insecure’ styles have difficulties in mentalisation and in using counter-transference responses in their practice. We suggest that family therapists, social workers and others engaged in therapeutic work with families should undertake an exploration of the ‘self’ of the therapist in the context of their own family relationships and adult attachment styles as part of their training and continuing professional development.     

‘Steroids,it’s so much an identity thing!’ perceptions of steroid use,risk and masculine body image

This paper explores how taste and distaste, body image and masculinity play into young people’s perceptions of risk related to steroid use. Data are drawn from a qualitative study on risk-taking among 52 Danish youths enrolled in high school or vocational training. A number of ‘risky’ practices such as drug use, fights, speeding, etc. were discussed. In contrast to these practices, which were primarily described in relation to ‘physical risks’, steroid use was understood as part of an ‘identity’ or ‘lifestyle’ in a way these other risks were not. Few interviewees had used steroids, and the large majority distanced themselves from the practice. Reasons for not wanting to use steroids were related to (1) perceiving the drug to be part of a broader lifestyle and identity that they are not interested in committing to or embodying and (2) finding the body image, physicality and associations with steroid use ‘fake’, ‘gross’ and distasteful. We draw on recent developments in feminist sociological theory related to the gendered body as both a performance and process to understand steroid use as a practice through which the body and self is produced. More than a one-dimensional ‘risky’ practice, we argue that gendered and embodied identities are crucial to understanding the dynamics of steroid use.     

The Intersubjective Experience of the Physical Body in the Clinical Setting of Eating Disorders

This paper will illuminate one dimension of self-disclosure as it relates to the inescapable presence of the body in treatment, and the female clinician’s ability to bring her physical body into clinical discussions during an encounter with a female client with an eating disorder. Although the clinical literature on eating disorders validates that transference and countertransference issues are particularly powerful, it generally neglects the exploration of these issues specific to the body’s physical presentation. Since body dissatisfaction is increasingly normative for women today, female clinicians need to have a theoretical road map on which to rely when they encounter a shared body experience. Thus, in order to encourage discussions of the therapist’s body in clinical social work practice, the body needs to be situated in a larger theoretical framework within which it can be explained and located; this framework is object relations theory viewed through an intersubjective lens. Concepts from object relations theory will demonstrate the importance of the body in the clinical exchange by highlighting the parallel between Winnicott’s ‘good enough’ mother and the ‘good enough’ therapist’s body. When the therapist is able to judiciously invite discussions of her body into the clinical arena, the client is given the opportunity to move from object relating to object usage. A case presentation exemplifies how this conceptual framework can be applied to clinical social work practice, strengthening the relationship between knowing and doing.     

Looking for a ‘cure’: negotiating ‘walking’ in a Turkish rehabilitation hospital

This article explores discourses surrounding ‘walking’ in a Turkish rehabilitation hospital and their impact on in-hospital relationships, patients’ attitudes towards disability, and constructions of ‘bodily normality’. Interviews were conducted with 29 patients, 11 medical personnel, and two non-medical personnel. Three categories of discourses emerged. First, hope for walking is kept alive in doctor–patient relationships, either through a state of silence on the matter or an emphasis on time, determination, and faith in God. Second, patients are virtually assured of the retrieval of walking, mostly through interactions with fellow patients and their accompanying family members (refakatçis). Third, a possible non-walking future is highlighted, either within a framework closer to a disability rights perspective or through an emphasis on gratitude. Diverse discourses on walking emerge due to the informality of in-hospital practices. Still, the ‘normal body’ is predominantly reproduced as the ‘walking body’. Thus, patients refuse discharge before regaining the ability to walk.     

Observing the Rites of Autonomy,Distancing the Prospects for ‘The Spiritual’

We are acculturated to believe each healthy person is a firmly bordered republic, a kind of self‐sufficient island. With its associated values entitlement and self‐determination, this assumption has become an internalised schema within which individuals — and many therapists — evaluate personal competence and adjustment. Whilst acknowledging that an expectation of autonomy might encourage ambition and empowerment, the injunction ‘be autonomous’ may also bring with it a number of unintended consequences. These include the promotion of experiences of isolation and incompleteness, experiences that many find uncomfortable and which may come to be associated with an emerging desire for what might be called ‘the spiritual’. A question then arises: might an expectation of personal autonomy on the one hand prompt a yearning for spiritual experience yet, on the other, diminish the prospects of such an experience by marginalising the possibilities of personal and interpersonal connectedness? After developing this argument, I offer preliminary ideas to assist practitioners to envisage how the ‘secularly spiritual’ might be imagined and invoked within everyday therapeutic practice.     

Body-States,Body Image and Dissociation: When Not-Me is ‘Not Body’

The relationship between dissociation, eating disorders and disordered eating is key as it relates to dissociative disruptions to body image. It undermines normal integration of appearance-relevant information and cuts off access to subjective experience and feeling states necessary to form an internal representation of one’s self and body. This vulnerability contributes to body image distortions and the uncritical internalization of society’s notion of the thin ideal—which is an unrealistic standard, that leads, in turn, to body dissatisfaction. Patients with eating disorders live under the assumption that if they feel their sensations and feelings these will overwhelm them ‘forever’. The fear of being consumed by these terrible feelings, leads them to believe that ‘not feeling’-or even not existing-is the only answer. Being able to tolerate one’s subjective, affective experience is part of being able to internally represent one’s states, including body-states and to develop a stable experience of body image.     

“I am a cheerleader,but secretly I deal drugs” Authenticity through Concealment and Disclosure

Authenticity requires a balance between being true to others and being true to the self. People keep and disclose secrets in order to maintain authenticity contextually within relationships, as well as across contexts through self‐reflexive evaluations. Based upon a content and discourse analysis of 1600 submissions to the PostSecret mail‐art project, this study explores how secrets are used to manage disparate social, role, and personal identities to sustain coherent selves in some contexts and incoherent selves in others. Secrets are revealed anonymously through the PostSecret mail‐art project, which allows for a cathartic release without disrupting their performances in front of significant others. This project analyzes the attempts made to maintain or achieve authenticity through the dialectical acts of concealment and disclosure.     

Women leaders,self‐body‐care and corporate moderate feminism: An (im)perfect place for feminism

This article offers self‐body‐care as an aspect of corporate moderate feminism and a manifestation of postfeminism for women leaders. It explains how postfeminism as a bodily practice surfaces through women leaders' body work and how women ‘top' leaders strategize to stabilize their credibility by identifying their own and other women' body work needs and the steps they take to meet these. Self‐body‐care extends understandings of body work as part of postfeminist governmentality and contributes to understandings of moderate feminism as that which deflects and reflects feminism and constrains and empowers subjects. As such self‐body‐care offers an (im)perfect space for disruption and for Gender and Organization Studies (GOS) scholars to pursue the implications and potential of postfeminism. We call for women elite leaders to be part of feminist futures and illustrate self‐body‐care as an aspect of corporate moderate feminism by highlighting complexity in the postfeminist thesis and reflexively re‐examining two of our previous published empirical studies of women ‘top' leaders.     

Theory,practice and use of self in the open dialogues approach to family therapy: A simple complexity or a complex simplicity?

In the family therapy literature there is increasing interest in the dialogical approach, particularly as it becomes well‐grounded in psychotherapy research. One embodiment is ‘open dialogues’, which has developed over a 30‐year period in Western Lapland, Finland. This paper outlines my experience of visiting Keropudas Hospital in Tornio, Finland, the birthplace of open dialogues. It explores the seven theoretical principles of open dialogues, associated elements of clinical practice, and the therapist use of self. The author utilises these aspects to reflect on dialogical moments through words and images based on three conceptual themes, which illustrate the relevance of open dialogues for family therapy practitioners and their contexts.     

User Involvement in Therapy: Couples' and Family Therapists’ Lived Experiences with the Inclusion of a Feedback Procedure in Clinical Practice

User involvement in therapy includes some form of feedback from the clients. The feedback guides the therapist and the clients toward a best possible result through a best possible therapy process. In recent years many different procedures for collecting feedback have been developed. In a previous study presented in this journal we explored the expectations therapists had before including the comprehensive clinical feedback procedure, Systemic Therapy Inventory of Change (STIC), in their clinical practices. Our aim with this present study is to explore couples' and family therapists’ experiences with STIC from the perspective of user involvement. We found that the term ‘using STIC’ represented many different variations both between therapists and between the families each therapist worked with. Likewise user involvement, combined with a feedback procedure like STIC, was also a many faceted area. We discuss how therapists’ experiences may relate to the different aspects of user involvement in therapy.     

Treating Trauma Through Three Interconnected Lenses: Body, Personality, and Intersubjective Field

The neuroscience of trauma in increasingly oriented to the importance of understanding right brain to right brain dynamics and helping the therapist to respond to implicit communication, which is discussed, as well as Porges’ polyvagal theory. The traumatized patient presents a variety of challenges to clinicians, including a dysregulated autonomic nervous system (ANS), compromised ability to self-soothe and diminished capacity for relatedness with others. Therefore, one effective approach to treating trauma (especially dissociation) includes conceptualizing and responding to our patients through three separate but interconnected lenses: (1) patient and therapist as human mammals—orientation to the ANS, (2) patient and therapist as personalities—orientation to the internal world and, (3) patient and therapist as inhabiting an intersubjective field together—orientation to shared, co-created body/psychological states. The capacity to be guided by countertransference is an especially valuable skill for therapists, as well as the ability to know when they are being experienced as helper or adversary by their patients. Different dynamics driving dissociation and different strategies for responding to the dissociating patient are discussed. Clinical examples are included.     

’Tis Beauty Kills the Beast: Aesthetic and Sensory Transformations of Encapsulated States

The author examines a particular form of addictive exploitation of sensory experience to extend Meltzer’s concept of claustrum states. She elaborates how bodily experience—both the patient’s and the analyst’s—is key to emergence from these states. Following the distinction between holding and containing made by Bion and Cartwright, the author traces the reciprocity of meaning making through the analyst’s seeing/sensing of beauty in the patient, noted by the analyst’s erotic response to a coming-alive self, allowing for aesthetic reciprocity and transformation.     

'Estrogen-filled worlds': fathers as primary caregivers and embodiment

Within the wide body of scholarship on gender work and caring, sub‐strands of research have grown tremendously in the past decade, including largely separate studies on fatherhood and embodiment. Drawing on a qualitative research project with Canadian fathers who self‐identify as primary caregivers of their children, this article focuses on recovering largely invisible links between theoretical and empirical understandings of fatherhood, caring and embodiment. The article builds on the work of key sociologists of the body as well as the work of Goffman and Merleau‐Ponty. Specifically, Merleau‐Ponty's concept of ‘body subjects’ and Goffman's work on the ‘moral’ quality of bodily movements through public spaces are utilized as lenses for understanding fathers' narratives of caring, particularly how men speak about their movements with children through what several fathers refer to as “estrogen‐filled” worlds. As caring for others involves forming social networks and relations, embodiment can matter in the spaces between men, between male and female caregivers, and between men and the children of others. This article argues that through the changing stages of caring for children, male embodiment constantly shifts in the weight of its salience in the identities and practices of fathers and caregiving.     

‘Spirits,dancing in the flesh’: choreography and organisation

ABSTRACT

The body in organisations has received considerable scholarly attention, whilst the moving body and the ‘flesh’ has largely been overlooked. ‘Flesh’ for Merleau-Ponty connects the body and the world and supposes not an immobile, but moving body. We explore flesh as a movement-related, kinaesthetic phenomenon through a movement/dance-based method and interviews with professionals from a hospitality/service organisation. We apply the notion of ‘choreography’ from dance studies, composed of the elements of ‘writing’ (graphós) and ‘movement’ (chorós). Our findings show that fleshly movement interaction creates invisible structures, or choreographies, that are inscribed into bodies and tacitly confine organisational interaction (‘writing’). Bodies learn to relate to each other through perceptual interpenetration and kinaesthetic empathy and co-create the choreography (‘moving’). Fleshly movement interaction is a submission to choreographies fulfilling the organisational need to reproduce bodies capable of carrying out certain movement imperatives, which however provides momentary openings through the use of kinaesthetic empathy.     

Keeping up appearances: aesthetic labour in the fashion modelling industries of London and New York

This paper addresses itself to literature on ‘aesthetic labour’ in order to extend understanding of embodied labour practices. Through a case study of fashion modelling in New York and London we argue for an extension of the concept to address what we see as problematic absences and limitations. Thus, we seek to extend its range, both in terms of occupations it can be applied to, not just interactive service work and organizational workers, and its conceptual scope, beyond the current concern with superficial appearances at work and within organizations. First, we attend to the ways in which these freelancers have to adapt to fluctuating aesthetic trends and different clients and commodify themselves in the absence of a corporate aesthetic. The successful models are usually the ones who take on the responsibility of managing their bodies, becoming ‘enterprising’ with respect to all aspects of their embodied self. Secondly, unlike Dean (2005 ) who similarly extends aesthetic labour to female actors, we see conceptual problems with the term that need addressing. We argue that the main proponents of aesthetic labour have a poorly conceived notion of embodiment and that current conceptualizations produce a reductive account of the aesthetic labourer as a ‘cardboard cut‐out’, and aesthetic labour as superficial work on the body's surface. In contrast, drawing on phenomenology, we examine how aesthetic labour involves the entire embodied self, or ‘body/self’, and analyse how the effort to keep up appearances, while physical, has an emotional content to it. Besides the physical and emotional effort of body maintenance, the imperative to project ‘personality’ requires many of the skills in emotional labour described by Hochschild (1983 ). Thirdly, aesthetic labour entails on‐going production of the body/self, not merely a superficial performance at work. The enduring nature of this labour is evidenced by the degree of body maintenance required to conform to the fashion model aesthetic (dieting, for example) and is heightened by the emphasis placed on social networking in freelancing labour, which demands workers who are ‘always on’. In this way, unlike corporate workers, we suggest that the freelance aesthetic labourer cannot walk away from their product, which is their entire embodied self. Thus, in these ways we see aesthetic labour adding to, or extending, rather than supplanting emotional labour, as Witz et al. (2003 ) would have it.     

Returning to psychotherapy with the same therapist: A self psychological perspective

Terminations or interruptions of psychotherapy which have been followed by a patient's resuming therapy with the same therapist at a later time have often been viewed as premature with the implication that the initial therapy has been inadequate or deficient. This paper suggests, however, that a patient returns to the same therapist because the selfobject bond established in the initial treatment is still intact, and that the hiatus between treatments can be a time of further development and strengthening of self structure. Two clinical cases are described which illustrate these ideas.