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REPAIRING THE BROKEN MIRROR: A THEORETICAL DANCE/MOVEMENT

THERAPY MANUAL FOR THE TREATMENT OF WOMEN WITH BULIMIA

by

Ariele L. Riboh

© 2009 Ariele L. Riboh

A thesis
submitted in partial fulfillment
of the requirements for
the degree of Master of Science
(Dance/Movement Therapy)
School of Art and Design
Pratt Institute

October 2009 

Repairing the Broken Mirror ii

REPAIRING THE BROKEN MIRROR: A THEORETICAL DANCE/MOVEMENT

THERAPY MANUAL FOR THE TREATMENT OF WOMEN WITH BULIMIA

by

Ariele L. Riboh

Received and approved:

______________________________________ Date _____________________


Thesis advisor -Valerie Hubbs, MS, ADTR, NCC, CGP, LCAT, LMHC

______________________________________ Date _____________________


Chairperson—Jean Davis, MPS, ATR-BC, LCAT
Repairing the Broken Mirror iii

TABLE OF CONTENTS

LIST OF TABLES………………………………………………………………………...v
ABSTRACT……………………………………………………………………………...vi

Chapter

1. Introduction………………………………………………………………………..1

History of Eating Disorders


Defining Eating Disorders
Medical Etiology
Psychological Etiology
The Mother-Infant Relationship
Mismatches and Impingements
Trauma
Role of the Media and Body Care Industry
Dance/Movement Therapy Treatments

2. Methodology……………………………………………………………………..32

Rationale
Apparatus
Participants
Procedure
Data Collection and Analysis

3. Results……………………………………………………………………………37

DMT Theoretical Practices


Treatment Themes and Goals
Movement Characteristics
Movement Interventions
Transference and Countertransference
Therapist’s Self-Care
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4. Discussion………………………………………………………………………..48

Findings
Literature review
Questionnaire
Significant Findings and Recommendations
Need for collaboration
Need for Further Clarification and Exploration
Validity and reliability
Conception of movement patterns
Utilization of specific interventions
Monitoring DMT effectiveness
Therapist self-care
Study Limitations

REFERENCES………………………………………………………………………56

Appendixes…………………………………………………………………………..61

Manual…………………………………………………………………………...pocket




Repairing the Broken Mirror v

List of Tables

Table E1. Answers to Questionnaire Concerning DMT Experience of Participants.


Repairing the Broken Mirror vi

Abstract

Today eating disorders, in particular bulimia nervosa, are rising at an alarming rate

despite the current available treatments. Due to the somatic nature of this illness,

dance/movement therapy appears to be an appropriate and perhaps more relevant

therapeutic modality. In order to investigate this, a case study examining the work of four

dance/movement therapists working with women suffering from bulimia nervosa (BN)

was conducted. Factors examined included: themes emerging for patients in treatment;

movement characteristics; specific movement interventions; the therapist’s use of

transference and countertransference, and the self-care methods used by dance/movement

therapists. It seems that there are commonalities among women suffering from BN, such

as issues surrounding self-esteem and a sense of self. There also appears to be themes that

emerge in treatment that are characteristic of this population, such as shame and control.

Despite similar characteristics in certain areas, there was significant disagreement when it

came to the actual practice of dance/movement therapy (DMT).


Repairing the Broken Mirror 1

Repairing the Broken Mirror: A Theoretical Dance Movement Therapy Manual for the

Treatment of Women with Bulimia.

Today, the incidence of eating disorders is reaching concerning levels. According

to the National Institute of Mental Health (as cited in Eggers & Liebers, 2007), “0.5 to

3.7 percent of women develop anorexia nervosa and some 1.1 to 4.2 percent experience

bulimia nervosa (BN) in their life time” (p. 2). In addition to these troubling percentages

it appears that, despite treatment efforts, the prevalence of eating disorders continues to

increase in our Western society. According to the National Eating Disorder Association

(2006), the incidence of bulimia in the USA has tripled for women ages 10-39 between

1988 and 1993.

Many approaches have been used for the treatment of people with eating

disorders, including psychodynamic, action-oriented, cognitive-behavioral, interpersonal,

self-psychology, structural family therapy, developmental, feminist, pharmacological,

group and individual therapy, and short- and long-term therapy (Krantz, 1999, p. 83).

Studies with promising results have been conducted on the short-term effectiveness of

cognitive behavioral therapy and on interpersonal therapy. Yet, there are few studies that

show efficacy in the long-term treatment of this population. Although many modes of

treatment for eating disorders are currently in place, the recovery rates are relatively low

among patients receiving treatment with approximately 30% of full recovery for people

with anorexia and 50% for people with bulimia nervosa. In an effort to contribute

towards a more holistic and effective treatment of bulimia nervosa in women, the current
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study aims towards the compilation of a pilot treatment manual presenting

dance/movement therapy (DMT) as primary modality for the treatment of women with

BN.

History of Eating Disorders

Eating disorders are not new phenomena, and have been documented within

psychiatric literature since the 17th century. At that time, they were known as a nervous

disease or hysteria (Maine, 2009, p. 6). Different hypotheses regarding BN etiology have

since been explored.

Freud originally attributed eating disorders to “neurotic conflicts about sexuality”

(Maine, 2009, p. 7) he viewed these conflicts as involving “oral incorporative

mechanisms and oedipal genital wishes” (Schneider, 1995, ¶ 4). Schneider (1995)

suggests that Freud attributed the purging involved in bulimia nervosa to the following:

. . . [an underlying] oral sadistic, cannibalistic, sexual fantasy. This fantasy was

that, from the young, eating-disordered girl’s point of view, she could eat the

father’s penis and be impregnated with his baby (Freud, 1905/1953). Psychogenic

vomiting was the girl’s neurotic, hysterical symptom resulting from this

unconscious sexual conflict and subsequent compromise formation. (¶ 4)

In the 1960s, behavioral treatment emerged as the popular choice of treatment.

Today, according to Vanderlinden (2008), cognitive behavioral therapy (CBT) remains

the treatment of choice and is highly recommended by most “evidence-based treatment

guidelines” (p. 329). As Vanderlinden explains, the CBT approach suggests that a

“dysfunctional scheme of evaluation” (p. 329) is central to the maintenance of eating

disorders. This signifies that most people suffering from eating disorders present
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unrealistic beliefs about their bodies and weight. CBT treatment is thus believed to target

these dysfunctional beliefs directly.

It was not until Hilde Bruch’s assessment of eating disorders in the 1970s, that

their origins were viewed as both biological and psychological. Bruch (as cited in

Schneider, 1995), in opposition with Freud, attributed eating disorders to issues that arose

during the separation-individuation process. She believed that eating disorders were an

unconscious struggle between the wish to be separate and the wish to remain one with the

mother figure.

Anorexia nervosa was the first identified eating disorder and the mental illness

now known as bulimia nervosa was initially seen as a subset of anorexia. In 1976,

Boskind-Lodahl identified a disorder known as bulimarexia, but it was not until 1979

with Russell that bulimia nervosa was named and differentiated as a separate disorder

(Maine, 2009, p. 7). Many studies have continued to explore the causes of eating

disorders linking their origin to primary biological abnormalities, gastrointestinal

problems, disruptions of various cerebral components, an inability to negotiate critical

developmental stages, cultural and societal influences, and several other causes.

A number of studies have investigated the etiology of these disorders, yet there is

much discordance in the findings and a notable lack in longitudinal studies. Waller and

Sheffield (2008) claimed that studies have had “a tendency to investigate factors in

isolation . . . [and that they] focus on diagnostically pure groups which fail to reflect [real

life] clinical populations” (p. 152). A significant amount of research has been done to

investigate the phenomenology of eating disorders and many plausible hypotheses have

been put forward. However, none have lead to significant scientific data serving to either
Repairing the Broken Mirror 4

confirm or deny the etiology of eating disorders. In a recent report, the U.S. Department

of Health and Human Services (as cited in Maine, Davis, & Shure, 2009) “lamented the

lack of reliable, clinically relevant empirical findings and emphasized the importance of

more qualitative studies to broaden the base of available treatment information and

expertise” (p. i). It is thus necessary to further understand the lack of reliability of current

studies and explore alternative options for the effective treatment of eating disorders.

Many risk factors are thought to be associated with this mental illness, including

genetics, family experiences, traumatic experiences, as well as a host of other factors that

can be attributed to environmental and socio-cultural influences. However, specific

responsible factors have yet to be determined.

According to Krantz (1999), “Eating disorders refer to disturbances of eating

behaviors and body-image distortions with underlying psychodynamic, cultural, and

gender conflicts” (p. 82). It is essential to identify a clear definition of eating disorders in

order to understand the implications of their complex etiologies and their effects on

treatment options.

Defining Eating Disorders

According to Davis (2009), eating disorders are primarily psychological disorders

as, “food and eating are symbolized or given meaning beyond ordinary nourishment and

consumption and because, as food and eating is symbolized, a variety of medical,

psychological and social problems are created” (p. 36). Anorexia nervosa is primarily

characterized by the refusal to eat and by a low body weight accompanied by significant

body-distortion. The main symptoms of BN are recurrent episodes of binging and


Repairing the Broken Mirror 5

purging by self-induced vomiting, abuse of laxatives, and vigorous exercise (Krantz,

1999, p. 82).

According to the American Psychiatric Association Diagnostic and Statistical

Manual of Mental Disorders (2000) text revision, eating disorders are “severe

disturbances in eating behaviors” (p. 583), and anorexia nervosa is defined as “a refusal

to maintain a minimally normal body weight” (p. 583). Anorexia is divided into two

subtypes: restrictive and binge-eating/purging type. The anorexic person is said to fear

the thought of gaining weight or becoming fat and is subject to significant body image

distortion (p. 583). This fear is not alleviated by weight loss and one often utilizes drastic

measures such as minimal caloric intake, frequent mirror checking, and repetitive weigh-

ins in an attempt to alleviate subsequent anxieties. This weight loss is often dramatic and

represents a health hazard that can lead to death. Weight loss appears to give the person

with anorexia a sense of self-control and any weight gain is seen as a dramatic failure (p.

584). Several physical side effects, such as amenorrhea and the growth of lanugo, a form

of peach-like hair all over the body, are present as diagnostic features. There are also

psychological symptoms that accompany this illness which are thought to be a result of

starvation. Such symptoms may be expressed as “depressed mood, social withdrawal,

irritability, insomnia and diminished interest in sex” (DSM-IV-TR, 2000, p. 585).

Obsessive-compulsive features, such as “preoccupied thoughts of food” (p. 585) and rigid

thinking, have also been identified as symptoms.

According to the DSM-IV-TR (2000) text revision, bulimia nervosa is defined as,

“repeated episodes of binge eating followed by inappropriate compensatory behaviors”

(p. 583). A binge is defined as, “eating in a discrete period of time an amount of food that
Repairing the Broken Mirror 6

is definitely larger than most individuals would eat under similar conditions” (p. 589).

Bulimia nervosa is also divided into purging and non-purging types. However, the two

are very similar in their psychological development and symptomology. Binging

behavior is characteristically done in secrecy and is associated with intense feelings of

shame and guilt. The DSM-IV-TR (2000) text revision states that binging is “typically

triggered by dysphoric mood states, interpersonal stressors, intense hunger following

dietary restraint, or feelings related to body weight, body shape and food” (p. 590). This

behavior is utilized as a means of self-regulation and provides temporary relief for the

person. It is thought that often during these phases of binge and purge the person enters

into a dissociative state that is subsequently felt as an utter loss of control. In order to

compensate for this loss of control, many engage in compensatory behaviors known as

purging. The most common means of purging is by self-induced vomiting. Some 80% to

90 % of people with bulimia adopt this method of purging. Other disordered behaviors

are also used to compensate for binging behavior and to prevent weight gain. Such

behaviors include abuse of laxatives and diuretics, excessive exercise, fasting between

binges, and so forth. Associated with this symptomology, people suffering from bulimia

nervosa often suffer from depressed mood states and present symptoms fulfilling the

criteria for mood disorders, anxiety disorders, and personality disorders.

The DSM-IV-TR (2000) text revision also offers a definition for eating disorder

Not Otherwise Specified (NOS) among this diagnostic category. This category is utilized

for diagnosing all other eating disordered behaviors that do not fall under the criteria for

either anorexia or bulimia. Further diagnostic criteria and a detailed description of this

category can be found in the DSM-IV-TR (2000) text revision (p. 592), or in the desk
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reference to the DSM-IV-TR (2000) text revision (p. 265). Considering the complexity

and expansiveness of each separate diagnosis, it is beyond the scope of this study to

examine each diagnostic category in depth. The current study will focus solely on the

diagnosis of bulimia nervosa. Also, due to the overwhelming 90% incidence of this

eating disorder among women (Maine et al., 2009, p. xxii), the current study will solely

focus on the female population.

Now that a preliminary understanding of the symptomology of this disorder has

been presented, it is important to present the origins of this illness in order to better serve

potential BN patients.

Medical Etiology

Eating disorders are complex disorders that affect individuals not only mentally,

but also physically. According to Kaye (2008), eating disorders are currently of unknown

etiology; however, there is “growing acknowledgement that neurobiological

vulnerabilities make a substantial contribution to the pathogenesis of anorexia nervosa

and bulimia nervosa” (p. 121). These findings are not yet fully understood and more

studies are needed to further clarify the matter. Some researchers have attributed

neurological disturbances associated with eating disorders to neuropeptide dysregulation.

Neuropeptides are molecules involved in message transmission by neurons in the

brain/body communication process. Hence, neuropeptide dysregulation can directly affect

brain activity and body physiology (Kaye, 2008). For example, essential hormonal

activity, such as gonadal, thyroid, and so forth could be affected. However, it appears that

the disturbance of neuropeptides might be in itself the result of the eating disorder. Kaye

has noted that there are various hypotheses investigating the roles of monoamine neurons,
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tying abnormal levels of serotonin (5-HT), an essential neurotransmitter, to “appetite

dysregulation, anxious and obsessional behaviors and extremes of impulse control” (p.

124). This disturbance of serotonin level appears in parallel to the disorder and seems to

persist after recovery.

Twin studies on eating disorders have also been conducted and results suggest

that there is possibly a biological nature to these disorders. According to Kaye (2008):

There is approximately a 50 to 80% genetic contribution to liability accounted for

by additive genetic factors. These heritability estimates are similar to those found

in schizophrenia and bipolar disorder, suggesting that anorexia nervosa and

bulimia nervosa may be as influenced as disorders traditionally viewed as

biological in nature. (p. 122)

Also, with the advance of technology, recent research using brain-imaging techniques,

such as computerized tomography (CT) and magnetic resonance imaging (MRI), has

contributed to the emergence of new hypotheses about brain abnormalities in individuals

with eating disorders (Kaye, 2008). Although sample sizes and the number of studies are

limited, “differences in ill and recovered eating disordered individuals in frontal,

cingulated, temporal, and/or parietal regions compared to controls” have been observed

(Kaye, 2008, p. 125). Brain imaging studies have also shown elements such as atrophied

areas, enlarged ventricles, deficits in both grey and white matter, and decreased cortical

mass for individuals suffering from eating disorders (Kaye, 2008). Some of these

elements appear to normalize themselves with recovery from eating disorders, but again

these findings remain in their preliminary stages because of the lack of longitudinal

studies.
Repairing the Broken Mirror 9

Psychological Etiology

Having explored various medical hypotheses, it is important to explore other

models and schools of thought to fully understand the many components of this illness.

The following is an examination of the symptomology for bulimia established by the

Psychodynamic Diagnostic Manual (PDM) (2006).

According to the PDM (2006), depression, social isolation, low self-esteem,

anxiety, and loss of libido appear to be some of the predominant issues that arise for these

patients. Panoply of symptoms, feelings, and affective states can be linked to bulimia

nervosa. Common feelings that can accompany these affective states are “feelings of

being starved for care and affection” (PDM Task Force, 2006, p. 120), feelings of failure,

shame, anger, aggression, and loss of control.

The PDM (2006) advances the hypothesis that these emotions and affective states

emerge from cognitive patterns that have been established in the individual’s childhood.

Psychodynamic theoreticians also hypothesize that many of these affective states and

associated feelings and emotions emerge not only psychologically, but also somatically.

These somatic states seem to be frequently expressed as feelings of numbness and of

disconnection from or confusion about the body. Another area that appears to be

problematic for this population is that of relational patterns. Social isolation and difficulty

forming relationships are typically present. The PDM indicates that among these patterns,

issues around control, perfectionism, and secrecy emerge significantly. Indeed, the PDM

advances relevant hypotheses as to the etiology of bulimia and illustrates some of the

main characteristics of this population. These are essential elements for the current study,
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as they will aid in better understanding individuals suffering from eating disorders, hence

allowing for more comprehensive and adaptive treatment plans.

The Mother-Infant Relationship

From psychodynamic, self-psychology, and object relations perspectives, the

origins of eating disorders can be traced back to infancy. These approaches emphasize the

importance of the mother-infant relationship for the future psychological development of

the infant. From birth, an infant begins to learn about the world through the eyes and

body of the mother/caregiver. It is through this attachment that an interpersonal

relationship is formed between mother and infant and allows for the “immature brain [to]

use the mature functions of the parent’s brain to organize its own processes” (Siegel,

1999, p. 67). Through these processes, the child begins to learn modulation of positive

and negative feelings, forming the basis for the capacity to self-regulate. It is through the

formation of an adequate attachment between a mother and her infant that the infant is

able to establish and feel a sense of internal safety and emotional security which is “a

reflection of confidence in the availability of attachment figures”, which lead to a secure

attachment (Mitchell & Black, 1995, p. 136). The opposite is known as an insecure

attachment, which “may serve as a significant risk factor in the development of

psychopathology” (Mitchell & Black, 1995, p. 68).

It is also through the mother-infant relationship that the elements of merging and

differentiation come into play. Merging occurs when the infant and the mother’s internal

rhythms are synched and in tune with one another. Merging allows for the occurrence of

symbiosis and attunement, two essential elements in the creation of a secure attachment.

“Attunement involves the alignment of states of mind in moments of engagement during


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which affect is communicated with facial expression, vocalizations, body gestures, and

eye contact” (Siegel, 1999, p. 88). Through differentiation, which naturally results from

merging, the infant is able to develop a sense of identification, leading to the future

development of the self. Consequently, the self is developed “through the ongoing

process of identification with (or . . . merging) and differentiation between internalized

images of one’s own self and those of external objects-real objects or persons” (Pallaro,

1996, p. 113). This pattern of merging and differentiating, once internalized, will be the

basis of engagement for future relationships.

The role of the mother-infant relationship is also essential in the physical and

neurological development of the infant.

These relationships are crucial in organizing not only ongoing experience, but the

neuronal growth of the developing brain. In other words, these salient emotional

relationships have a direct effect on the development of the domains of mental

functioning that serve as our conceptual anchor points: memory, narrative,

emotion, representations, and states of mind. In this way, attachment relationships

may serve to create the central foundation from which the mind develops. (Siegel,

1999. p. 68)

The subjective experience of the infant as lived through the body is also of utmost

importance, as it is “the crucial and principal organizer of object representations in

infancy” (Pallaro, 1996, p. 114). Indeed, the infant begins with the identification of the

self as subject and it is through interaction with the parents and the family of origin that

the infant begins to develop a sense of self as an individualistic entity.


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As important as the mother/caregiver is for the psychological development of the

infant, one must not forget the importance of touch and physical contact between the

mother and the infant. Renee Spitz (as cited in Mitchell & Black, 1995), one of the first to

explore the significance of touch, studied children in orphanages whose basic needs were

met, but who were deprived of nurturance. He found that, after 3 months in these

conditions, the infants demonstrated reduced eye contact and appeared withdrawn and

depressed. By age 2, some had died and others were considered to be nonfunctional.

Referring to what he found as failure to thrive, Spitz explained that this phenomenon was

due to the lack of touch and adequate nurturance. Harry Harlow further explored the

importance of touch through experiments with baby rhesus monkeys that were separated

from their mothers. In Harlow’s experiment, the monkeys were provided two surrogate

mothers, one that was a wire doll with a bottle for feeding and one that was covered in a

soft material and was heated. The babies fed from the wire doll but immediately went to

the cloth doll for nurturance (Orbach, 2009, p. 47-8). Through this study, “[Harlow]

demonstrated that a sense of touch and warmth were crucial for bonding” (Orbach, 2009,

p. 47). These studies have been essential for understanding where elements of trauma and

impingement can occur in infancy. These may help formulate tailored interventions,

which can compensate for and help overcome deficiencies that potentially contribute to

eating disordered symptomatology.

It is also through the repeated and consistent contact with the mother’s body and

through the awareness of its own bodily sensations that the “infant develops its own

boundaries, as delimiting and containing a personal sense of self” (Pallaro, 1996, p. 114).

According to Orbach (2009):


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Every aspect of our body sense embodies something about our mother’s own

physicality. If she is awkward and physically reticent, we pick that up. If she is

bold or intrusive, our personal body sense will accommodate that in some form. If

she fails to touch us in a firm yet gentle manner, we may become confused or

fearful about our bodily sensations. We might not know where our body begins

and where it ends. (Orbach, 2009, p. 50)

It can therefore be postulated that the skin represents the body’s boundary for the

self. It is consequently this physical boundary that allows for differentiation between

internal and external. This knowledge is of great importance, as women with bulimia

nervosa often struggle with elements of self-differentiation.

Mismatches and Impingement

Having explored the different ways in which the role of the mother-infant

relationship affects infant development, it seems clear that this critical relationship affects

not only the immediate experience of the infant and the satisfaction of his or her most

primitive needs, but that it also serves in the normal development of the self and of body

boundaries. Consequently these elements lay the groundwork for future relational

patterns, which fall into the different attachment categories established by Ainsworth.

These relational patterns consist of secure, anxious/avoidant, anxious/resistant (Tracy &

Ainsworth, 1981, p. 1341) or secure, avoidant, ambivalent and disorganized/disoriented

(Mitchell & Black, 1995). Ainsworth’s strange situation was a test done to investigate the

different types of mother-infant attachments. This study was conducted in a controlled

setting consisting of a playroom with a one-way mirror from which the researchers

observed. The actual study consisted of observing the interactions of a mother and her
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infant and the reactions of the child following the introduction of a stranger with and

without the mother present. A securely attached child is reportedly able to explore and

engage with strangers while the mother is present. However he/she will become

distressed upon the mother’s departure and will cease to engage with the stranger. The

infant is soothed and reassured upon the return of the mother. The anxious/avoidant

either avoids or ignores the mother and shows little emotion upon the departure or return

of the mother. Engagement with the stranger is similar to with the mother.

Anxious/ambivalent behavior is characterized by the infant demonstrating a significant

amount of anxiety around strangers even with the mother present. Upon departure of the

mother, the child is extremely distressed and when she returns the infant demonstrates

mixed emotions, where he/she might seek proximity but at the same time might attempt

to hit or push the mother. The last category, disorganized/disoriented, was an addition to

Ainsworth’s work. In this case the child becomes distress when the mother departs but

avoids and ignores her upon her return. The child might also demonstrate odd behaviors

such as freezing or falling to the floor upon the mother’s return (Wikipedia online

encyclopedia).

As seen above, the mother-infant relationship can be a subtle and quite intricate

one, and even when a mother is striving to be what Winnicott termed, the good enough

mother, “mismatches” (Stern, 1977, p. 140) can occur. These mismatches occur when

there are regulatory failures due to overstimulation, understimulation, or paradoxical

stimulation.

Overstimulation is often the result of a caregiver who is controlling and intrusive,

which in turn interferes with the infant’s ability to self-regulate. As a result of these
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behaviors, the infant “may then be forced to develop more extreme regulating or

terminating behaviors” (Stern, 1977, p. 140). This overstimulation by the caretaker also

sends the message to the infant that he or she cannot regulate his or her external world or

internal experiences through emotional communications. If this behavior of

overstimulation is chronic, the infant will progressively display inhibited motor

expression and affective facial expressions.

If a mother is depressed, schizophrenic, inhibited due to character pathology or

has a limited repertoire of social behaviors, under-stimulation of the infant can occur.

Further, if the infant “is hypoactive or has a significant developmental lag or minimal

brain damage, then a normally effective amount of stimulation may not move him up to

or keep him within the optimal range” (Stern, 1977, p. 148) and under-stimulation may

be the result.

Mothers who respond appropriately to their infants only in the case of danger or

distress are examples of paradoxical stimulation. These caregivers are often referred to as

neglectful or abusive. Indeed, such caregivers only become animated when the infant

who has a “‘repertoire’ of common self-hurtful or discomforting mishaps [displays these

behaviors]. . . . Many of these mishaps are funny in the way that slapstick is funny, and

most caregivers may laugh (if there is no real injury)” (Stern, 1977, p. 149). However the

paradigm that is learned by the infant in these instances is that of masochism, or “pain as

the condition for pleasure” (Stern, 1977, p. 150). Another form of paradoxical stimulation

is that of the “mutual approach-withdrawal dance” (Stern, 1977, p. 150). This form of

stimulation can lead to difficulties during the negotiation of separation-individuation.


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These types of interactions with the mother form the basis for later relational

patterns of the infant. If, indeed, these are troublesome and inadequate, they can lead to

difficulties in social interactions and relationships, which appear to be characteristic of

many women with bulimia.

Separation-individuation is a model of infant development established by

Margaret Mahler (Mitchell & Black, 1995, p. 43). This model reinstates the role of the

caregiver as capital for the future psychological development of the child. The process of

separation-individuation is divided into three sub-phases. The first is hatching, which

takes place from 0 to 9 months. During this phase, the infant demonstrates “increased

alertness” (Mitchell & Black, 1995, p. 46), a more outwardly directed gaze that is used to

check back with the mother/caregiver as a point of reference. Following this, is the sub-

phase of practicing, where the toddler is “infused with a sense of omnipotence: despite

actual moving away from his mother, he experiences himself, physically, as still one with

her, sharing in her perceived omnipotence” (Mitchell & Black, 1995, p. 47). Finally, from

15 to 24 months, the child reaches the sub-phase of rapprochement in which the child

undergoes “physic disequilibrium” (Mitchell & Black, 1995, p. 47). This disequilibrium

is experienced as the realization of the physical and mental separation that begins to

occur. The once fearless toddler begins to lose his or her previous sense of omnipotence

and fear begins to settle in. The constant desire for proximity with the mother reappears.

During development, all of these sub-phases are essential as they contribute to the

development of the child’s ego and ability to self-regulate. Newton (2005), further notes

that if the mother/caregiver is not emotionally and physically available, the infant is

susceptible to ego deficiencies and disturbances. These deficiencies and disturbances can
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lead to poor ego strength, which can manifest itself in many forms, such as poor coping

mechanisms including difficulty coping with stress. These appear to be issues

encountered in the bulimic population. Newton postulated that:

If this was not experienced psychological ego development may become

vulnerable to self-pathology, with disturbances in internal and external object

representations corresponding to sub-phases in separation and individuation. Pine

(1979) articulates two adult self-pathological manifestations. A “lower order”

disturbance is marked by an uncertain self and other boundaries, leading to a loss

of self. A “higher order” disturbance is distinguished by an inability to tolerate

aloneness, by attempts to reestablish coercive omnipotent control over external

objects, and by object constancy deficits. (p. 173)

As a result of these mismatches, impingements, and lack of consistent nurturance, the

infant can develop a sense that there is something “not quite right” (Orbach, 2009, p. 81)

with him or her. In consequence to this feeling of inadequacy, the infant develops a

misconstrued sense of self. Orbach saw this as the grounds for the development of a false

self.

There are numerous ways in which the mother/caregiver and the infant develop a

relationship. Ultimately, one hopes that a caregiver will be able to encompass the

qualities of Winnicott’s concept of good enough mother, which provides optimal levels

of frustration tolerance and nurturance, and which avoids impingement (Mitchell &

Black, 1995, p. 129). Impingement occurs when the mother fails the child by “allowing

external stimulation to reach painful levels, by intruding into the base state of drifting

quiescence, or by allowing the child’s internal needs to build to frustrating levels”


Repairing the Broken Mirror 18

(Mitchell & Black, 1995, p. 209). In other words, impingement can be understood as the

failure of the mother “to protect the delicate state necessary for psychological growth and

health” (Mitchell & Black, 1995, p. 209).

Unfortunately, there are many interactions possibilities that can lead to what

Beattie (1988) described as:

[a] child with an ego structure inadequate to the tasks of autonomy and self-

regulation, with little capacity to monitor inner bodily states such as hunger and

satiety, and with a resulting tendency to act out conflicts over independence and

self-control via excessive control of the body and its food intake. (p. 453)

This reinforces the idea that to develop a healthy ego and a sense of self, the infant must

be raised in an adequate environment that stimulates normal development.

According to Mahler (as cited in Mitchell & Black, 1995), mental illness is the

direct result of a basic failure of an individual to form a self (p. 41). This failure can be

understood as the non-negotiation of the process of separation-individuation or, more

specifically, the non-negotiation of any given sub-phase of the separation-individuation

process. It is hence fair to hypothesize that eating disorders could possibly emerge from

impingement, poor development of frustration tolerance, inadequate nurturance, or any

combination thereof.

Trauma

Another unfortunate factor that can lead to impingement is trauma, resulting from

physical, verbal, and/or sexual abuse. According to Wonderlich, Brewerton, Jocic,

Dansky, and Abbott (1997), childhood sexual abuse (CSA) is a significant risk factor for

the development of bulimia (p. 1107). Many studies have evaluated the effects of abuse
Repairing the Broken Mirror 19

and its correlation to eating disorders. However, some general inconsistencies are

apparent and it is not clear how exactly childhood abuse “affects the basic symptom of

eating disorders” (Truer et al., 2005, p. 108). Yet, most of the literature agrees that there

is a positive correlation between abuse and bulimia. Leonard et al. (as cited in Brewerton,

2007) conducted a study in which “women with bulimia nervosa reported higher levels of

CSA, childhood physical abuse, and combined childhood sexual/ physical abuse

compared to the non-eating-disordered women” (p. 289).

In summary, genetic predispositions, neurological disturbances, troubles in the

mother-infant relationship and trauma need to be taken into account for the development

of therapy guidelines and dance/movement interventions. In addition to these personal

variables, one needs to acknowledge and understand the influence of external factors

such as the media, and the body-care industry on the development and maintenance of

eating disorders.

Role of the Media and Body care industry

In today’s consumption driven society where instantaneous satisfaction, easy

accessibility to products, competition, permissiveness, women’s stress and forced ideals

dominate, a pervasive marketing emphasis is placed on the body as a commodity. Daily

or even hourly, one is solicited by advertisements, magazines, media events and product

or service offers portraying standards and ways to make our bodies fit into the societal

ideals. “The sense that biology need no longer be destiny is gaining ground, and so it

follows that where there is a (perceived) body problem, a body solution can be found”

(Orbach, 2009, p. 2). Today, beauty no longer appears to be equated with individuality

and variety, but with set standards established by the media and body-care industry.
Repairing the Broken Mirror 20

One’s weight and shape now determines one’s place in society. Beauty and thinness are

associated with power and acceptability. As highlighted by Orbach, “The right body is

trumpeted as a way of belonging in our world today . . . while failing to get one’s food

and size right can signify shame, failure or a rejection of the values we are presumed to

aspire to” (pp. 3, 13).

Consciously or unconsciously the media and body-care industry induce women to

think that they are not good enough if they do not fit within societal norms of the “thin-

ideal” (Grabe, Hyde, & Ward, 2008, p. 461). The images and messages with which we

are regularly bombarded create a sense of shame, and when women fall short, it results

“in a sense of inadequacy” (Shure & Weinstock, as cited in Maine et al., 2009, p. 165).

As a result, women are put in a position where their bodies are the battlefields and they

are shamed for wanting to eat (p. 165). Acceptance and worth become associated with

repression of needs, and deprivation has become common lieu.

According to Grabe et al. (2008), 50% of undergraduate women report being

dissatisfied with their bodies, which is of particular interest, as “research from

prospective and longitudinal designs has identified body dissatisfaction as one of the

most consistent and robust risk factors for eating disorders such as bulimia” (p. 460).

Much research has been conducted examining the correlation between body-image

dissatisfaction, eating disorder symptomology and the influence of the media. According

to Grabe et al., laboratory experiments have been conducted with random samples of

women assigned to view thin-ideal and non-thin-ideal media stimulus. Following

exposure, levels of body dissatisfaction were measured. An overwhelming percentage of

women exposed to thin ideal stimulus reported an increase in body-image dissatisfaction


Repairing the Broken Mirror 21

(p. 461). One may however question these findings and the reliability of these studies as a

large percentage of women are regularly exposed to thin-ideal media, yet, only a fraction

report being dissatisfied with their body image, and an even slimmer fraction develop an

eating disorder. One may hence question the role of the media as either causal or

supportive.

In summary, it is apparent that eating disorders, among which BN, are complex

illnesses associated with a genetic predisposition, external factors such as environment,

the mother-infant relationship, trauma, family dynamics, media, and so forth. These

variables can enable and exacerbate eating disorders. Also, it appears that despite the

availability of current psychiatric, physiological, and behavioral modes of treatment, the

incidence of bulimia continues to rise. Accordingly, dance/movement therapy appears to

be equipped to contribute innovative treatments dealing uniquely with body awareness,

self-expression as well as body-mind integration through a more targeted method of

treatment.

Dance Movement Therapy Treatments

As with any discipline, DMT has evolved since its conception in the 1960’s with

Marian Chace. Although most therapists base their practices on widely acknowledged

concepts and principles that are central to DMT, there is quite a panoply of approaches

that can be used for the treatment of women with BN. To fully understand the application

potential of these options, their review is warranted.

Krueger, a psychiatrist, and Schofield, a dance/movement therapist, have been

working with eating disordered populations for over 20 years. Informed by

developmental theories, they have assumed a “deficit model” (Krueger & Schofield,
Repairing the Broken Mirror 22

1986, p. 325), which hypothesizes that individuals suffering from an eating disorder have

a developmental deficit resulting from an impingement or a frustration, which arose

during critical developmental stages. Stagnation, in Krueger and Schofield’s experience,

appears to have occurred in the following areas: “sense of self, separation-individuation,

somatic recognition and expression with the maturing desomatization to take one’s body

for granted, to live in and through one’s body” (p. 326). This model also hypothesizes

that the mother has failed to acknowledge and confirm a separate body self for the child,

thus leading to a distorted body image and body self.

Building on these hypotheses, Krueger and Schofield (1986) have developed a

therapeutic model targeting these specific variables to ensure a comprehensive treatment

plan. They state that, “a combination of verbal and nonverbal techniques is as imperative

as the integration of body self and psychological self” (p. 325). According to Krueger and

Schofield, this treatment model relies on the collaboration between a psychiatrist and a

dance/movement therapist to synthesize “mind and body in a cohesive manner” (p. 326).

This model has been used both in the context of an inpatient and outpatient setting and it

is customized according to the patient’s needs.

The goals of this model of treatment are to foster body-mind integration, to help

patients develop the capacity to “symbolize and play” (Krueger & Schofield, 1986, p.

327), and to promote transmuting internalization, a term coined by Kohut, describing the

“inherent impetus to go forward in one’s development” (Rowe & MacIssac, 1995, p. 61).

Although the primary modalities utilized in this model are verbal psychotherapy and

DMT, projective drawing and videotaping are also utilized. Treatment begins by working

with an “internal focus of bodily sensations, feelings, and awareness” (Krueger &
Repairing the Broken Mirror 23

Schofield, 1986, p. 327). This is done in order to simulate a normal development between

infant and mother, and is intended to help the patient actively “define the original body

self in a cohesive manner” (Krueger & Schofield, 1986, p. 327). Treatment then

progresses through the developmental stages, utilizing targeted therapy interventions,

such as mirroring, relaxation, and centering.

Anne Krantz (1999), another dance/movement therapist who works with eating

disordered populations, has created a model of treatment that is based on the methods of

Blanche Evans, a DMT pioneer. Krantz’s model assumes the following:

(a) Meaningful affective information is exchanged between the mother’s and

child’s bodies from before birth throughout development; (b) the body is the

vehicle for expressing and storing life experience; (c) the child requires genuine

interaction with caregivers in order to become a separate individual, able to

connect with others; and (d) where emotion is not experienced, particularly

distressing affects may become misinterpreted or disconnected from psycho-

physical reality. Disconnected affect may lead to symptoms, which impact the

body and behavior. The eating disorder is seen as a cumulative effect of disrupted

development of self, body, affect and relatedness. (p. 84)

According to Krantz (1999), Blanche Evans’ methods revolved around the

principle that “by regenerating the body’s potential to move, both emotional and mental

states can be changed” (p. 84). Given the psychosomatic characteristics of eating

disorders, DMT is uniquely suited for the treatment of this population. In Krantz’s

opinion, women with eating disorders often attribute the origin of their suffering to their

bodies. It appears that one’s body becomes the battlefield for repression, dissociation, and
Repairing the Broken Mirror 24

denial of emotions and sensations. Hence, one can see the applicability of DMT, since it

engages the body as an ally in the treatment process rather than as an impediment. Evans

also hypothesized that individual characteristics and one’s environment influence a

person’s life; and indeed, that stress and trauma can become embedded in the body’s

muscle memory as tensions and restrictions. Evans thus believed that it must be through

movement that these elements are worked out and released. This is done through the

exploration of the unconscious and the individual’s use of defense mechanisms,

resistances, and so forth.

Building on Evans’ theories, Krantz (1999) claimed that many clients with eating

disorders have a predisposition towards the use of dissociation, which leads to a split

between the body and the self, often due to early failures in the mother-infant

developmental process of “experiencing affect, body, self and others” (p. 85). DMT is

thus used to reconnect this split, to achieve a harmonious body, and to aid in the

development of self-knowledge and insight, utilizing the body as a “point of reference,

and a vehicle for expression” (p. 85).

Krantz (1999) also believed that it is through movement that one must address

body image distortions so as to aid in the creation of “a dialogue between the subjective

feelings and attitudes, and the body reality” (p. 86). It is both through movement and

through the therapeutic relationship that the body image begins to clarify itself and

become more realistic.

According to Krantz (1999), sexuality also appears to be of great relevance when

dealing with body image, as it is related to issues surrounding “self-image, autonomy,

and self-assertion; give and take; letting-go and control; intensity of body feelings and
Repairing the Broken Mirror 25

sensations; tension and apathy; and the limits of potential action” (p. 86). Specifically,

Krantz believed that “sexual conflicts are intrinsic to eating disorders, whether or not

sexual abuse has occurred” (p. 87). Krantz further claimed that, for some, the eating

disorder replaces sexual experiences. This hypothesis is based on her observations of

patients associating highly sexualized movements with themes such as eating and

vomiting.

In order to adequately treat women with eating disorders, Krantz (1999) has

suggested that the therapist must be curious as to how the woman defines herself in the

world: her sexual history, her family history, her ability to experience pleasure, and so

forth. This allows the therapist to identify areas in which the eating disorder has

“functioned to prevent the client from knowing about these experiences” (Krantz, 1999,

p. 87). Krantz also states the importance of working with the body, from the very start of

treatment in an expressive way, and of working “with what the client brings” (p. 88).

Krantz utilized several specific methods including mobilization, a technique that

“encourages self-created spontaneous movement exploration and reconnection of

movement and feeling, leading to expanded expressiveness” (Evans, as cited in Krantz,

1999, p. 88). This method is used to help mobilize the body to develop “new alternatives

for movement and expression” (Krantz, 1999, p. 89). Physicalization is also a specific

technique created by Evans and utilized by Krantz to transform “an experience into

action with feeling” (Krantz, 1999, p. 89). This method encourages the patient to

communicate an experience through movement instead of only talking about it.

Physicalization is said to aid in the discovery of inner experiences. Improvisation is


Repairing the Broken Mirror 26

another tool often utilized to awaken the unconscious, which can lead to the discovery of

unused potentials and repressed materials.

Another method called Functional Technique is used as a “non-stylized dance

technique, which is rehabilitative and re-educative” (Krantz, 1999, p. 90). This technique

utilizes specifically targeted movement exercises for the individual so that “as the client’s

feelings change, her body must change in order to physically support the new feeling

state, and to counteract unconscious repetition of the problem” (Krantz, 1999, p. 90).

Homework is also useful as a means of facilitating the applicability of treatment

in the patient’s day-to-day life. According to Krantz (1999), homework can serve “to help

the client study patterns of eating and purging, to identify their emotional triggers, and to

create healthier alternatives” (pp. 91-92). Real life situations are also integrated into the

treatment and explored in order to ease the transition from therapy to everyday life.

Methods, such as rehearsal, are employed to help alleviate anticipatory and situational

anxiety. Although these rehearsals are not strictly DMT-specific, they can help the patient

practice alternative methods for coping with anxiety in a safe environment before having

to confront the real situation.

The methods applied vary depending on the therapist’s individual therapeutic

approach and on the needs of the patient. Stark, Arronow, and McGeehan addressed the

topic of the treatment of individuals with bulimia nervosa in their article,

“Dance/Movement Therapy with Bulimic Patients” (1989). Stark et al. state that dance is

a direct expression of the self through the body and is thus a powerful tool for the

treatment of the eating disorder population. Given the repressive, dissociative, and

somatic nature of this disorder, the authors believe that movement experiences can help
Repairing the Broken Mirror 27

patients reconnect with their body and learn to identify areas of tension that are often

associated with repressed emotions and feelings. Stark et al. also stressed the

development of social skills as an essential part of treatment and asserted the need for the

therapist to support the patient in developing new coping mechanisms and strategies.

Stark et al. (1989), identified three main goals for the treatment of patients

suffering from bulimia nervosa: “(1) the body and its action; (2) interpersonal

relationship; and (3) self-awareness” (Stark, as cited in Hornyak & Baker, 1989, p. 123).

The body and its action represent the idea that one must begin to aid the patient in

activating the body through movement. This allows for the release of areas of tension and

repressed feelings. It is postulated that through this activation of the body, cathartic

release, the development of a more realistic body image, bodily integration and

coordination can occur. When it comes to interpersonal relationships, it is postulated that

through the use of rhythm, a sense of relatedness can occur in the group experience. Such

relatedness through rhythm can foster identification with others; it can allow for the

development of self-awareness and can provide a learning opportunity for new movement

options. Finally, the third goal of self-awareness is based on the concept that, through

movement and the experience of the body, one can promote a deeper sense of self-

understanding and self-knowledge.

According to Stark et al. (1989), other specific goals in the treatment of bulimia

are to:

Develop trust; develop body-awareness and a more realistic body image . . . a

clearer sense of self and body boundaries; encourage autonomy and enhance self-

esteem; encourage more appropriate interpersonal relations, thereby overcoming


Repairing the Broken Mirror 28

loneliness, isolation and depression; and facilitate identification, tolerance, and

expression of emotion in appropriate, constructive ways. (p. 127)

Having discussed treatment goals, corresponding examples of movement interventions

are then presented. These are discussed in terms of Mahler’s object-relations theory. The

first goal presented is that of developing trust in the therapeutic relationship, as it mirrors

the original symbiotic relationship between infant and caregiver. However, special

attention is brought to the fact that there is often a need to address nurturance, safety, and

acceptance before a trusting relationship with the patient can be established. Elements

such as body awareness and body trust might also emerge as elements needing to be

negotiated before the development of a trusting relationship can occur. To illustrate these

concepts, several specific interventions are listed accordingly.

The first example highlights empathizing with the patient through mirroring and

synchronization in order to understand the patient more clearly and to give the patient the

“experience of being understood and accepted on an unconscious body level” (Stark et

al., 1989, p. 128). Next, the use of touch and massage is elicited to aid in the development

of trust.

The following sets of interventions are aimed at increasing body awareness and

promoting positive body image. Stark et al. (1989) suggested that through increased body

awareness, one can begin to differentiate their own bodily signals, thus creating a sense

of control over their “body and eventually over the external world” (p. 130). To aid in the

development of this bodily awareness, simple use of breath is of utter importance. It is

through rhythmic and synchronized breathing that a special and intimate relationship is

developed between mother and infant, thus it is an essential tool for the therapist.
Repairing the Broken Mirror 29

Breathing is also used as a tool in the reconnection with the body, which often leads to

the discovery of areas of tension and sensation. Other means utilized in the development

of body awareness are interventions, such as body scans and focalization on specific body

parts. Techniques such as Feldenkrais, Alexander, and the Bartenieff fundamentals can

also be used (Stark et al., 1989, p. 132).

For women with BN, the development of body awareness is essential in laying the

foundations for the formation of positive body image. This, in turn, can help establish a

sense of self, differentiation and body boundaries. Stark et al. (1989) point to the

importance of developing strong body boundaries as this helps patients with BN contain

and tolerate “the intense feelings they have previously controlled through binging and

purging” (p. 133).

The next Malherian phase is that of separation-individuation, which is associated

with the development of autonomy and self-esteem. To begin the developmental process

of establishing autonomy, Stark et al. (1989) emphasized the need for patients to

experience “their real body center and the two weight centers. This includes a clear sense

of balance and awareness of stability and mobility in both the upper and lower parts of

the body” (p. 135). Having renegotiated the separation-individuation process, one must

begin to learn about the other/not-me modes of social interaction and ways of developing

healthy and appropriate interpersonal relationships.

The next treatment step is associated with the rapprochment phase in Mahler’s

developmental theory, which deals with interpersonal relationships. Since social isolation

is often associated with mental illness, it is of great importance to aid the patient in

reconnecting with others and developing appropriate relationships with peers. These
Repairing the Broken Mirror 30

elements are thought to help sustain remission. It is often postulated that people with

bulimia have great difficulty being authentic in relationships and that “the real self in

touch with spontaneous impulses, feelings, and desires is split off and repressed. As a

result, bulimics often attempt to validate themselves through others” (Stark et al., 1989, p.

137). It is therefore important for the dmt to devise interventions that help these patients

reconnect with their bodies and rekindle their creative expression to yield increased

pleasure from genuine social interactions.

The last goal in treatment, as defined by Stark et al. (1989), is “authentic self-

expression” (p. 139). The authors associate this goal with the developmental process of

object constancy, in which the child’s “own individuality begins to consolidate and one’s

contradictions find some resolution” (Mahler et al., as cited in Stark et al., 1989, p. 139).

It is through authentic self-expression that previously intolerable feelings can emerge and

that the patient can begin to reclaim control of his or her body and of him or herself in

relation to others. The development of authentic movements can also help the patient

learn modes of self-regulation.

In order to help women suffering from bulimia nervosa reclaim and find their

authentic self, a method known as authentic movement is often used as a modality of

treatment for this population. Authentic movement was created by Mary Stark

Whitehouse and was highly influenced by Jungian theory, in particular by a concept

known as active imagination:

The process Jung used was meant to provoke unconscious images using as little

conscious intervention as possible. The patients were instructed in how to become

conscious witnesses of their own unconscious process and then to enter the scene,
Repairing the Broken Mirror 31

becoming part of the picture or action. After the images stopped, the patients were

asked to write, draw, or paint the story. (Taylor, 2007, p. 48)

Whitehouse worked with this idea and applied it somatically, utilizing movement as the

means of tapping into the unconscious process. Indeed, this method focuses on the

internal experience of the person moving and, consequently, the therapist’s role is

indirect, as the observer/witness. It is a powerful tool, as Musicant (2001) described:

The mover is involved in an immediate, direct, and intimate relationship with the

self in the presence of another. This process can be profound as clients are seen

and accepted as they enter the unknown in themselves and listen deeply to

themselves. For those whose relationship to their own knowing has become

distorted, this process can be both challenging and healing. (p. 20)

As seen above, there are many approaches for the treatment of women with

bulimia nervosa, even within the field of DMT. It is thus one goal of this study to directly

solicit information from experienced DMT practitioners to evaluate the existing methods

and to put forth a comprehensive overview of movement interventions.


Repairing the Broken Mirror 32

Methodology

Rationale

According to Wilson, Grilo, and Vitousek (2007), “The development of more

efficient treatments will depend on improved understanding of the mechanisms whereby

psychological treatment produces therapeutic change” (p. 205).

Building on this concept, a case study design (Cruz & Berrol, 2004, p. 72) was

used for this study, which focused on the analysis of the current use of DMT as a primary

means of treatment for women suffering from bulimia nervosa. In particular, the

principal investigator sought to understand when and how DMT could be utilized and

what factors conditioned the effectiveness of this therapy.

For this purpose, the investigator reviewed relevant literature and solicited input

from professional dance movement therapists with significant experience and recognized

expertise in treating bulimia in North America.

The goal of the study was to compile the learning acquired from therapists with

the knowledge selected from the literature review into a treatment manual for

practitioners working with women suffering from bulimia nervosa and utilizing

dance/movement therapy as the primary modality for treatment.

The manual, which will be presented as a pocket appendix, would cover the

following main topics:

1. ED fundamentals

2. Etiology
Repairing the Broken Mirror 33

3. Eating disorder symptoms

4. Diagnosis

5. DMT treatment themes

6. DMT treatment goals

To begin with, the principal investigator conducted a review of the literature,

utilizing primarily scholarly, peer-reviewed, and primary source references when

possible. Secondary and tertiary references were only used when primary sources were

unavailable. In order to adequately understand the population being studied and to

increase the reliability of the information and the hypotheses or conclusions drawn, the

principal investigator incorporated literature from a variety of fields including

psychology, psychiatry, nursing, social work, and alternative therapies. Through this

research, an update of the etiology, development, and maintenance of bulimia nervosa in

women, as well as treatment implications, was obtained.

Apparatus

Input from experienced DMT therapists was acquired through a questionnaire (see

Appendix A) created by the author and distributed for completion to registered

dance/movement therapists. The questionnaire was designed according to the knowledge

and guidelines extracted from the literature review. The questionnaire design aimed at

gaining firsthand knowledge from the experienced clinicians concerning the mechanisms,

characteristics, and treatment implications for patients with BN. It was also utilized to

evaluate proposed movement characteristics observed in women diagnosed with bulimia

nervosa, as well as to assess the relevance and effectiveness of specific movement

interventions selected from DMT literature. Another goal of the questionnaire was to
Repairing the Broken Mirror 34

examine the roles of transference and countertransference between patient and therapist.

The last goal was to understand modes of self-preservation used by the therapists.

The 15 questions developed to address all these elements were composed as

follows: The first three questions requiring short answer responses were utilized to obtain

information on the therapists, their experience, and their professional orientation;

Questions 4-7 consisted of Likert scale responses evaluating characteristics of the

selected population and prompting for further information; Questions 8-10 evaluated

specific interventions; and Questions 11 and 12 utilized both Likert scale responses and

short answers to explore the therapists’ use of transference and counter-transference. The

remaining questions sought to explore the effect, if any, of this work on the therapist and

her/his methods of self-preservation.

As stated, the questionnaire was ultimately developed and utilized in order to

assess the accuracy of information gathered through the review of literature and to

evaluate specific interventions for their potential inclusion in the final manual.

Participants

Participants were recruited on a voluntary basis through extensive e-mailing (see

Appendix B), to the American Dance Therapy Association’s (ADTA) listserv and

through personal contacts of the investigator. The participants ultimately recruited were

female. Two dance movement therapists were located in New York, one in Florida, and

one in Canada. The participants worked both in individual and group treatment settings,

such as inpatient hospitalization programs, outpatient day treatment, and private practice.

To qualify for participation in this study, participants were required to be registered dance
Repairing the Broken Mirror 35

therapists (ADTR) by the American Dance Therapy Association and have a minimum of

5 years experience treating patients with eating disorders.

Procedure

Participants were asked to complete the questionnaire that was submitted either

electronically, via a secure email account, or via a hard copy, and an optional semi-

structured interview was utilized when deemed necessary.

In order to abide by ethical standards established by Pratt Institute, by the ADTA,

and by the American Psychological Association (APA), each participant was required to

fill in a consent form (see Appendix C) informing them of the potential risks and benefits

of participating in the study. Participation in this study was voluntary, and all participants

were informed of the purpose of the study and of their right to refuse and/or to cease

participation at any time without consequences. Participants were treated with the utmost

respect and in accordance with standards established by the organizations mentioned

above.

Participants were encouraged to respond within 45 days upon receipt of

questionnaire and to complete and return documents to the principal investigator. No

remuneration was attributed to participants. All sensitive information was kept in a

locked drawer by the investigator in her locked apartment. To further ensure privacy,

each participant was assigned a confidential code. The response data was then coded by

an alphabetical system identifying the participants.

Following receipt of the completed questionnaires, the principal investigator

evaluated the need to utilize a 30-minute semi-structured interview (see Appendix D) to

further clarify or to expand on information gathered from the questionnaires. These semi-
Repairing the Broken Mirror 36

structured interviews were to be conducted via phone or in person, depending on the

availability of the participants. The responses to the questions were to be recorded via

note taking and/or via voice recording.

To ensure the security of sensitive material, all data will be deleted and destroyed

within 6 months of completion of the thesis project and the email account will be

permanently closed. Hard copies of information will be retained for no less than 3 years.

No other person will have access to the information.

Data Collection and Analysis

The quantitative data gathered from the questionnaire was summarized in four

sections of the Results chapter: treatment goals and themes that emerged during

treatment, movement characteristics specific to patients with BN, specific movement

interventions, transference, countertransference, and self-care of the therapist. For each

numerical question (scored on a Likert scale, ranging from 1 to 5) response frequency

was calculated to assess its relevance for inclusion in the manual. All data was

summarized in a table (see Appendix E). Qualitative responses were transcribed and

summarized for each participant according to section themes. When necessary, direct

quotations were used to remain authentic to the answers provided by the participants.

These responses were included in the manual according to topic and relevance for

treatment. Only data deemed relevant was compiled to create a DMT manual for

practitioners treating women with bulimia nervosa.


Repairing the Broken Mirror 37

Results

The following section consists of a descriptive analysis of the data collected via

responses to the questionnaire (see Appendix A). A mass email (see Appendix B) was

sent to the American Dance Therapy Association listserv and four respondents expressed

interest in participation and represents the final sample size.

The identities of the dance therapists were kept confidential through letter coding

(A, B, C, and D). Each dance/movement therapist had a minimum of 10 years clinical

experience with an eating disordered population. Participants A, B, and C had over 45

years of cumulated experience working with women with eating disorders. Participant D

was not included in this calculation as this particular question was left blank.

The questionnaire consisted of Likert scales ranging from 1 to 5 and short answer

questions which sought to explore the mechanisms, characteristics, treatment

implications, and movement characteristics of this population. It also sought to assess the

applicability, utility, and effectiveness of specific movement interventions, to examine

the roles of transference and countertransference between patient and therapist, and to

understand modes of self-preservation used by the treating therapists. Data was scored

accordingly. For a full description of the raw data and select writing samples please see

Appendix E.

After an in-depth review of the data (as presented in Appendix E), only significant

findings will be presented in the following sections: DMT theoretical practices, treatment
Repairing the Broken Mirror 38

goals and themes, movement characteristics, movement interventions, transference and

countertransference, and therapist’s self care.

Significance of the data from the entire questionnaire was determined by the

principal investigator based on repetition of themes found in the literature and in the

participants’ responses. Also, based on the thorough responses and wealth of information

gathered via the questionnaires, the optional interviews were not utilized as initially

outlined in the Method Section.

DMT Theoretical Practices

As highlighted previously in the literature review, it appears that DMT is uniquely

suited for the treatment of eating disorders and, in particular, of bulimia nervosa. As

specified in the Psychodynamic Diagnostic Manual, people suffering from bulimia often

experience feelings of numbness, as well as feelings of disconnection from or confusion

about the body (PDM Task Force, 2006, p. 120). According to participant B “all

successful therapy involves an interaction between the mind and the body.” This concept

of body-mind integration is a primary focus in DMT. Indeed, DMT is the

“psychotherapeutic use of movement as a process which furthers the emotional, physical

and cognitive integration of the individual” (ADTA, as cited in Levy, 2005, p. 11).

Keeping the body-mind connection as an omnipresent guideline, the DMT

participants reported utilizing dance/movement therapy theories as a basis for their

practice. The dance/movement therapists reported utilizing concepts advanced by field

pioneers, including Marian Chace, Mary Whitehouse, and Blanche Evans. They also

reported being influenced by prominent psychological figures, such as Sullivan and Jung,

and adhering to concepts put forward by psychoanalytic, feminist, object-relations, and


Repairing the Broken Mirror 39

attachment theoreticians. As presented in the literature review, through the exploration of

various DMT treatment theories, such as Krantz (1999) and Stark et al. (1989), it is

visible that there are many ways within DMT to approach the treatment of BN. This

element of variety was salient as participants reported informing their approaches to

therapy through different means.

Treatment Themes and Goals

Having explored the dance/movement therapists’ theoretical frameworks and

clinical experience, the questionnaire sought to further explore their methods of

treatment. In particular, it sought to understand and predict therapeutic goals and themes

that might emerge over the course of treatment. Several goals appeared to emerge

consistently throughout the literature, among which reducing binge-purging behavior,

addressing body image distortion, increasing one’s ability to self-regulate, increasing

one’s connection to one’s body, and expanding one’s movement vocabulary, spatial

awareness, and spontaneity. These goals were evaluated in the questionnaire through a

Likert scale, ranging from 1 not applicable to 5 extremely relevant (see Appendix E,

Question 4). Participants A, B, C, and D all rated reducing binge/purge behaviors,

increasing self-esteem, and increasing a sense of body-self as extremely relevant. Both

participant A and B rated all of the above goals as extremely relevant and participant C

and D rated the above goals from relevant to extremely relevant, thus supporting their

importance and relevance for treatment. The participants were also invited to share goals

specific to their practices. Responses included: improving social skills, helping manage

stress, increasing one’s ability to express emotion, increasing creativity and play, and

understanding one’s relationship to food and eating (see Appendix E).


Repairing the Broken Mirror 40

Predominant themes emerging throughout the course of treatment were also

evaluated in the questionnaire through a Likert scale, ranging from 1 never to 5 all the

time (see Appendix E, Question 5). These themes were evaluated in order to increase the

principal investigator’s general therapeutic knowledge and to aid in the development of

specific and efficient movement interventions to be included in the final manual. The

theme of control was rated as emerging often by participant C to all the time by A and B.

The DSM-IV-TR (2000) text revision indicates that elements of losing control emerge for

those suffering from bulimia, especially surrounding instances of bingeing and purging.

The theme of control was again referenced by Krantz (1999) and was hence deemed

significant. The DSM-IV-TR (2000) text revision also alludes to depression, which

participants also rated as emerging often to all the time. Anxiety also stood out, both in

the literature and in the responses to the questionnaire, and was therefore deemed

significant. The theme of most important significance was that of shame. As all 4

participants rated it as emerging all the time.

Once again the participants were given the opportunity to share themes that they

considered relevant. Participant D suggested the inability to experience pleasure.

Participants B and C mentioned various forms of trauma (developmental, violence, and

neglect). As Truer et al. (2005) have stated, there appears to be a positive correlation

between abuse and the development of bulimia nervosa. In fact, Leonard et al. (as cited in

Brewerton, 2007) conducted a study in which “women with bulimia nervosa reported

higher levels of CSA, childhood physical abuse, and combined childhood sexual/physical

abuse compared to the non-eating-disordered women” (p. 289). Thus, trauma as a general

category was deemed of high significance.


Repairing the Broken Mirror 41

Movement Characteristics

According to Stark et al. (1989) and Deihl (1999), there appears to be movement

characteristics that are specific to women with bulimia nervosa, which include stopping

and going, lack of shaping, rigid pelvis, and so forth (p. 45). The questionnaire evaluated

the suggested movement characteristics found most often in the literature and their

relevance in current DMT practices through a Likert scale, ranging from 1 strongly

disagree to 5 strongly agree (see Appendix E, Question 6). For this question, participant

A’s answers were not incorporated as she reported, “guessing” to respond that she does

not “access in this way.” Out of the 7 movement characteristics proposed in the

questionnaire, 4 were deemed significant. These four characteristics were described as

relevant in the literature and the participants agreed and strongly agreed that these

movement patterns were characteristic of women with BN and the characteristics were

mentioned either directly or indirectly in the optional responses (Question 7). The

characteristics deemed significant were: a lack of movement in the chest, rigidity of the

pelvis area, a primary utilization of peripheral movements, and an indirect use of space.

Participants B and C also provided supplemental input and suggested several other

characteristics including: “lack of integration between upper and lower body”; “lack or

energy in or connection to the pelvis”; “agitated urgency and little sense of time”; and

“minimal movements in the near reach zone.” For movement characteristics there

appeared to be less agreement between participants in comparison to previous questions.


Repairing the Broken Mirror 42

Movement Interventions

Having examined individual approaches to therapy, goals, themes, and movement

characteristics, the next step was to explore the actual therapy process as seen through the

utilization of specific movement interventions. These interventions were taken from

examples offered in the DMT literature (Deihl, 1999; Krantz, 1999; Krueger & Schofield,

1986; Stark et al., 1989; Totenbier, 1995).

Overall, the responses to this question were quite different for each participant.

Responses ranged from 1 never use to 5 use all the time (See Appendix E, Question 8).

There were three categories of movement interventions were rated as use often (4) to use

all the time (5) by 3 of the dance/movement therapists and hence deemed significant.

These were improvisation, centering exercises and relaxation techniques. Participant C

reported utilizing authentic movement all the time. Apart from the significant use of

improvisation, centering, and relaxation techniques, no other conclusions were drawn

from this question. It appears that the dance/movement therapists’ background and

informing theories influence their choice of interventions.

Continuing with the evaluation of specific movement interventions, 11

interventions were described (see Appendix E, Question 10) and the dance/movement

therapists were asked to evaluate them via a Likert scale, ranging from 1 not effective to 5

extremely effective. Here, again, it was difficult to find sufficient participant agreement,

as the responses were quite diverse. Nevertheless, the use of physicalization was

evaluated by 3 participants (A, B, and C) as extremely effective and hence deemed

significant by the principal investigator. Participants suggested other interventions


Repairing the Broken Mirror 43

including: mirroring, walking meditation, focus based exercises, and sculpting of feeling

states. Participant A reported that she “work[ed] with process rather than providing

specific dance techniques.” She reported picking up on and developing the patients’

movements, emotions, and verbalizations in order to understand and help them

understand their issues.

Transference and Countertransference

Having explored the treatment process and the characteristics of this population, it

was of interest to explore the experience of the treating therapists through their use of

transference and countertransference. This was done via a Likert scale, ranging from 1

never use to 5 use all the time (see Appendix E, Question 11). Participants A, B, and C

reported using transference regularly to all the time. Participant D reported not using it at

all as she worked in a short-term setting. However, its use was deemed significant. Freud

(as cited in Dosamantes-Beaudry, 2007) originally referred to transference as the

“patient’s reproduction of past relationships in the current relationship established with a

neutral analyst” (p. 75). This definition has evolved over the years, but is generally

understood as “an unconscious phenomenon in which the patient transfers core feelings,

ideas, and methods of relating onto the figure of the psychoanalyst” (Waska, 2008, p.

333). Dosamantes-Beaudry also referred to somatic transference, which she defined as

the following:

The totality of the patient’s bodily-felt experience and enacted behavior

(experienced as bodily-felt sensations and expressed via bodily-felt expressive

movement and through kinesthetic and kinetic images) that function as


Repairing the Broken Mirror 44

transitional objects for the patient and provide critical relational psychodynamic

meaning that at the outset of treatment is unknown to the patient. (p. 76)

Participant A reported utilizing transference “sometimes actively and sometimes

passively,” either verbally or through movement, situation depending. Participant B

described transference as “important diagnostic information” that allows her to gain

important information about clients and their inner world. She also utilizes transference

to guide her in her work with individuals. Participant C explained that she too used

transference as a way of gathering information about the client, but that she only

addressed it with the client when deemed necessary and/or beneficial for the client and

the therapeutic process.

Next, participants’ use of countertransference was rated via Likert scale, ranging

from 1 never to 5 use all of the time (see Appendix E, Question 12). Participant A

reported using countertransference regularly, participant B rarely, participant C

moderately, and participant D all the time.

According to Racker (as cited in Dosamantes-Beaudry, 2007), there are two forms

of countertransference:

(a) concordant countertransference reactions in which the analyst felt compelled

to identify empathically with the patient’s thoughts and feelings and (b)

complementary countertransference reactions where the analyst experienced

himself being transformed by the patient into an unwanted or despised aspect of

the patient’s self. (p. 75)

Participant A alluded to countertransference as a means of gathering information

about patients. Similarly, participant D reported that the use of countertransference


Repairing the Broken Mirror 45

served as a means “to understand metaphors of their [the patient’s] experience and to

understand useful and not useful responses within the context of the therapeutic

relationship. Participant A emphasized, however, that it “always need[s] to be considered

as hypotheses, not the ‘truth’ of the client.” Participant A reported paying attention to the

emotions/feelings that emerge for her in the therapeutic relationship and seeking to

understand the underlying issues that are emerge for the patient. She gave the example of

feeling anxious, angry, or impatient as a potential indicator of the patient’s fear of

survival or of annihilation. She reported holding these emotions and reflecting them back

to the patient in a more neutral manner that allows the patient to work with them in a less

threatening fashion. Participant A also referred to the use of somatic countertransference,

which is of particular interest to the field of DMT. She defined somatic

countertransference as cues that emerge in her own body that may be “clues to what

might be happening in clients.”

Dosamantes-Beaudry (2007) defined somatic countertransference as “somatic

reactions a therapist has toward her patient at a particular moment during treatment” (p.

76). Orbach (2004), a leading psychologist in the field of eating disorders, also argued

that, contrary to popular trends, one must pay attention to these body symptoms that

patients bring forth, as they can serve as fundamental keys to the patient’s mental state

and may potentially be signs of “disorganized body attachment(s)” (p. 142).

In a similar fashion, participant C reported beginning a session by noticing what is

occurring in her body and by assuming that the countertransference is induced. She then

questions what patients want her to know about them. However, she reported not
Repairing the Broken Mirror 46

involving her countertransference directly into the session, but rather using it to

understand the client’s experience.

Participant B chose not to respond to this question and gave no explanation.

Therapist’s Self-Care

Considering the fact that the dance movement therapist utilizes her body in a

multitude of ways in the therapeutic relationship, it seems inevitable that this work would

have an effect on her. The questionnaire sought to understand if indeed this was the case

and if the participants’ work with women suffering from BN affected their sense of body-

self and their body image (see Appendix E, Question 13). Participants were asked to

evaluate the effect of their work via a Likert Scale, ranging from 1 never to 5 most of the

time. Participant A reported the work rarely affecting her. Participant D reported it

affecting her sometimes in that her use of eating as a defense mechanism was heightened.

Participant B reported it affecting her more than often in that it has made her highly

aware of ways in which she has “been brainwashed by the cultural images of beauty and

[she has had] to work to counteract those consciously to find all bodies beautiful.” In her

own words, “It has affirmed and strengthened the commitment of my own journey to

value my body as home and expression of my presence in the world.” Similarly,

Participant C also reported a heightened awareness of cultural ideals of beauty, but that

this work had predominately brought more awareness to her own relationship with food

and eating.

Methods of self-care were then explored (see Appendix E, Question 15). The

main methods utilized overwhelmingly by all 4 therapists were one-on-one supervision,

peer supervision, and group supervision. The other self-care options were rated according
Repairing the Broken Mirror 47

to personal preferences. Due to unclear participant completion of this question, specific

ranking could not be determined.

In conclusion, it is apparent that the dance/movement therapists selected to

participate had extensive clinical experience working with women with eating disorders

and, in particular, with women suffering from BN. Although all trained in DMT, the

therapists differentiated themselves by their individual approaches to therapy. Through

their responses, significant elements concerning the BN population were deduced. First,

therapeutic goals that emerged as significant were those of reducing binge/purge

behaviors, increasing self-esteem, and deepening a sense of body-self. The unanimous

theme that emerged as significant was that of shame. Movement patterns were difficult to

assess, due to little agreement in the responses. As far as proposed interventions,

improvisation and physicalization emerged as significant. Transference was deemed

important as a diagnostic tool and was often utilized, whereas countertransference was

utilized much less frequently. The therapist’s self-care evaluation was difficult to score as

responses varied, but the three following modalities emerged as significant: one-on-one

supervision, peer supervision, and group supervision.

Overall, there was significant agreement on elements surrounding psychological

factors and characteristics of this population. However, the picture became unclear

around questions concerning DMT theories and practices. What does this mean and what

are the implications for the use of DMT as a therapeutic modality for this population?

These questions need to be examined through more extensive surveys as suggested in the

discussion chapter.
Repairing the Broken Mirror 48

Discussion

In an effort to understand the increasing prevalence of BN in today’s society

(despite the available treatments), the principal investigator evaluated current literature

and research. In addition, experienced dance/movement therapists were surveyed about

characteristics and needs of patients with BN, themes emerging during treatment,

therapeutic goals, treatment methods, specific movement interventions, and self-care of

the therapist. The ultimate goal of this research was to compile a pilot manual for

therapists utilizing DMT as the primary modality in the treatment of women with BN (see

Pocket).

Findings

Literature review. The literature review provided a summary of the fundamentals

that dance movement therapists need to know when applying their skills to the treatment

of eating disorders, and specifically to BN. However, this review identified more

information about causes, symptoms, and therapeutic goals associated with BN illness

but less input about themes for intervention and recommendations for specific movement

patterns. The literature review also helped reveal the most significant factors and methods

of treatment available, to date, for the construction of the proposed manual.

Questionnaire. The questionnaire utilized for this case study contributed a rich

and diversified qualitative input. Through it, the author was able to gain insight into the

practices of four experienced dance/movement therapists. The information gathered via


Repairing the Broken Mirror 49

the questionnaire confirmed elements found in the literature and revealed areas needing

clarification and further exploration.

The data collected via the questionnaire served to support and confirm the themes

and goals of treatment considered relevant in the literature, but also allowed the

participants to share information and thoughts on other goals and themes that they

deemed important. The questionnaire also served to evaluate the current usage and

applicability of specific methods and interventions and allowed the author to collect

further information and ideas for specific movement interventions to be compiled in the

pilot manual. The questionnaire also helped bring to light areas that needed further

exploration; namely, better insight into the actual use (how, when, and why) of specific

interventions, a need to further monitoring and recording patient’s responses to the

different interventions, a systematic and normalized recording of the patient’s progress,

and so forth. Furthermore, it served to highlight the diversity and wealth of options one

has to choose from when utilizing DMT methodology.

In light of these findings, the principal investigator suggests that for future

research which utilizes this thesis model, the questionnaire be further revised to help

clarify elements such as dance/movement therapists’ training, reasoning for the

utilization of specific methods, and means through which effectiveness of methods were

established, in addition to the areas mentioned above. The author believes that this would

help researchers better understand the usage of DMT with women suffering from BN,

allow for an more thorough review of current treatment options, and allow for a more

complete conceptualization of a treatment manual.


Repairing the Broken Mirror 50

Significant Findings and Recommendations

Need for collaboration. The information gathered through the literature review

and the results collected via the questionnaire support the premise that DMT is an

appropriate means of treatment for BN, due to the somatic nature of BN and the body

oriented approach of DMT. It is also apparent, through the debate surrounding the

etiology of BN (medical and psychological), that there are multiple dimensions that must

be taken into consideration for the effective treatment of this illness. It is hence apparent

that preserving current team model of treatment is essential, but that the inclusion of

DMT in this model could contribute infinitely towards a more holistic and effective

treatment plan.

Need for Further Clarification and Exploration

Validity and reliability. As seen in the literature review, there are various methods

recorded by experienced DMT clinicians that have been deemed efficient (Deihl, 1999;

Krantz, 1999; Krueger & Schofield, 1986; Stark et al., 1989; Totenbier, 1995). However,

it is unclear how the validity, reliability, and effectiveness of these interventions were

established. This lack of information about the methods used to assess specific treatments

was also visible in the questionnaire. It is hence recommended that, upon revision of the

questionnaire, these elements be included and further explored in order to promote

technical validity of DMT methodology.

Conception of movement patterns. Through the literature analysis and the

responses recorded from the questionnaire, it became evident that the translation of

therapeutic goals into specific movement patterns emerged as a major challenge. While
Repairing the Broken Mirror 51

the literature analysis and the surveyed therapists revealed a number of pertinent

movement patterns, this contribution was relatively modest and not sufficiently

documented. Moreover the therapists’ feedback did not exhibit sufficient agreement on

particular movement patterns, but it did show the diversity of movement interpretations.

The literature review showed that specific suggestions for movement patterns originated

from a rather limited number of specialists (Deihl, 1999; Stark et al., 1989). These

observations show that DMT applied to BN has established some solid roots, but it is a

rather young discipline, which is still in the freelance experimentation phase. The author

believes that this is perhaps a normal evolution and that it could explain the current

diversity of approaches and prevailing disagreements.

Utilization of specific interventions. Significant concepts that emerged from the

questionnaire were an emphasis on the therapist-patient relationship and the therapist’s

ability to utilize elements such as transference and countertransference. These elements

emerged as techniques utilized to further understand the patient’s experience as an

individual and, in response, to tailor the treatment towards their specific needs.

Thus, it seems essential that DMT be practiced with great flexibility and openness

and that the therapist remains dynamic in order to cater to the individual’s healing

process. It is within this framework that the specific movement interventions were

evaluated.

Visible in the literature was the utilization of specific DMT methods, such as

physicalization and improvisation. These and other DMT interventions were evaluated in

the questionnaire in order to assess their utility and applicability in the treatment of

women with BN. This evaluation clarified the therapists’ preferences and agreement on
Repairing the Broken Mirror 52

the most effective interventions and underlined the flexibility with which one can practice

DMT. It also served to focus the selection of interventions to be included in the final pilot

manual.

There was, however, a visible lack in the literature on the specific application and

utilization of these interventions. There were no specific guidelines and one was left to

speculate as to their applications for individual or group settings, age appropriateness,

and so forth. These elements bring attention to the notable lack of outlined guidelines for

dance/movement therapists. Indeed there are no diagnostic or evaluative tools, such as the

DSM-TR-IV (2000) text revision, that help classify and organize acquired information. It

is evident that further investigation of standardized methods for diagnosing and treating

would be of great benefit to the field and for the teaching and transmission of knowledge

to colleagues in other medical domains, as well as, to new dance/movement therapists.

This may be a shortcoming of the questionnaire in that it did not sufficiently explore the

ways in which these methods were used. In consequence, the author would encourage

further clarification and exploration of the ways in which these interventions are used.

This would ultimately aid less experienced DMT clinicians in properly using the

proposed methods.

Monitoring DMT effectiveness. In acknowledging that DMT application to BN is

a relatively young discipline where creative experimentation by dance/movement

therapists prevails, there are several aspects that merit further attention. The author

believes that it is critical to formalize the process of monitoring the patient reactions, the

effectiveness of the movement interventions, and the coherence of all professional

interventions. This would not only help clarify the therapeutic process for less
Repairing the Broken Mirror 53

experienced dance/movement therapists, but it would also help to validate the field of

DMT at large. However, it appears that this important monitoring aspect has not yet

received sufficient attention, structuring, and coordination. Although this is not the sole

responsibility of DMT practitioners, the author encourages dance/movement therapists to

take a proactive role, possibly with the help of the ADTA, in shaping the monitoring

process and standards of treatment.

Therapist self-care. The literature review and feedback from the surveyed

therapists confirmed adequate awareness of the importance of self-care. It brought

attention to the critical use of supervision. The author believes that the use of supervision

demonstrates a willingness to examine one’s shortcomings and a desire to constantly

improve one’s ability to treat clients.

However, the extent and ways in which supervision is utilized was not clear. This

may be of interest for future examination to better understand therapists’ individual

therapeutic approaches and processes. It could further clarify the reasoning and

methodology behind specific interventions, which would be of great interest for the

future development of standardized methods and the development of treatment manuals.

Considering the level of direct mental and body involvement devoted by

dance/movement therapists to BN therapies, this author recommends that the DMT

community secures self-preservation through the identification of more self-care

techniques and training for their application. A meaningful initiative in this direction

would be to further organize with the ADTA and other BN health professional events,

such as national/international surveys, symposiums, and dedicated project task forces to

promote exchange and build consensus on best practices.


Repairing the Broken Mirror 54

Study Limitations

As in all research, unexpected limitations to this study emerged and reduced the

investigator’s ability to collect appropriate and relevant data. The first limitation and

perhaps the most significant one, was the limited timeframe and lack of funding. This in

itself restricted the sample size and the overall ability of the principal investigator to

conduct a more in-depth exploratory study. In particular, the author believes that future

studies would greatly benefit from the utilization of longitudinal outcome studies.

The limited number of willing participants was also a large impediment in this

study. Although, an email was sent to over 50 dance/movement therapists, only two

responded. The other two dance/movement therapists were recruited via personal request

of the principal investigator. It is unclear why so few dance/ movement therapists

responded. One might hypothesize that some dance/movement therapists might have

been reluctant to share therapeutic knowledge because of the difficulties translating their

work into words. Others might underline the possibility of resistance (perhaps

unconscious) to the development of the DMT field. Other practical considerations, such

as a lack of time, a lack of interest in the study, no compensation for completion, and so

forth could also have contributed to the low response rate.

In conclusion, this investigation has confirmed that the application of DMT to BN

is pertinent, but it is still in its developmental stage, which requires acceleration and

dealing with important issues such as those highlighted in the discussion. Future growth

and credibility of DMT application to bulimia would benefit from further consolidation

of DMT research advance, as well as from stronger coordination of interventions by all


Repairing the Broken Mirror 55

disciplines concerned with bulimia. This would further promote a holistic approach to the

treatment of BN in balance with its multifactorial complexity.


Repairing the Broken Mirror 56

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Repairing the Broken Mirror 61

Appendix A

Questionnaire

1) What are your professional credentials?

2) How many years have you worked with women diagnosed with bulimia nervosa?

3) What theories inform your work with this population?

4) Of the following options, please rate the treatment goals for women suffering from
bulimia nervosa according to relevance, utilizing the following scale.

1 2 3 4 5

not applicable slightly relevant relevant moderately relevant extremely relevant

a) Reducing of binge/purging behaviors

1 2 3 4 5

b) Reducing of body image distortion

1 2 3 4 5

c) Increasing self-esteem

1 2 3 4 5

d) Improving self-regulation

1 2 3 4 5

e) Developing better coping skills

1 2 3 4 5

f) Increasing sense of body-self

1 2 3 4 5
Repairing the Broken Mirror 62

g) Increasing body boundaries

1 2 3 4 5

h) Increasing spontaneity of movement

1 2 3 4 5

Please list other important treatment goals not mentioned above.

5) Among the following to what degree do these themes emerge in treatment for this
population? Please rate according to following scale:

1 2 3 4 5
never rarely sometimes often all the time

a) Control

1 2 3 4 5

b) Depression

1 2 3 4 5

c) Anxiety

1 2 3 4 5

d) Shame

1 2 3 4 5

e) Obsessive thinking

1 2 3 4 5

f) Obsessive behaviors

1 2 3 4 5

g) Sexual trauma

1 2 3 4 5
Repairing the Broken Mirror 63

Please list any themes that emerge in the treatment of women with bulimia nervosa that
were not mentioned above.

6) Please rate to what extent the following movement patterns are characteristic of
women with bulimia nervosa, utilizing the following scale.

1 2 3 4 5
strongly disagree disagree neither agree agree strongly agree
nor disagree

a) Purge position (a c-like curve, a sunken chest and a protrusion of the chin):

1 2 3 4 5

b) Lack of movement in chest:

1 2 3 4 5

c) Rigidity of pelvis:

1 2 3 4 5

d) Primary utilization of peripheral movements:

1 2 3 4 5

e) Difficulty grounding weight

1 2 3 4 5

f) Indirect use of space

1 2 3 4 5

g) Sporadic stop and go movements

1 2 3 4 5

7) Are there other movement patterns not mentioned above that you find characteristic of
this population?
Repairing the Broken Mirror 64

8) Please rate your personal use of the following interventions according to the following
scale:

1 2 3 4 5
never use use moderately use all the time

a) Guided Imagery:

1 2 3 4 5

b) Centering Exercises:

1 2 3 4 5

c) Relaxation techniques

1 2 3 4 5

d) Improvisation

1 2 3 4 5

e) Authentic movement

1 2 3 4 5

f) Bartenieff fundamentals

1 2 3 4 5

g) Props

1 2 3 4 5

9) Are there any specific interventions that you utilize regularly that merit attention? If
yes, please describe.

10) To what extent do you find the following movement interventions effective? Please
rate according to following scale.

1 2 3 4 5
Repairing the Broken Mirror 65

not effective somewhat never use / effective extremely


effective not applicable effective

a) Having the patient pick a hated or disliked part of the body, exaggerating its
size and having them move with this pretend exaggeration.

1 2 3 4 5

b) Self-touch to promote body boundary awareness.

1 2 3 4 5

c) Have the patient take two chairs that she places next to each other leaving
space in between them to represent her perceived width. Then having her verify
and adjust to become aware of potential misevaluation or distortion of reality.

1 2 3 4 5

d) Games such as freeze or red light green light to work on elements of starting
and stopping.

1 2 3 4 5

e) Physicalization (Blanche Evans) used to move an experience instead of talking


about it.

1 2 3 4 5

f) Functional technique (Blanche Evans) an individually catered dance technique


that is used to strengthen specific areas, retrain others and decrease tension in
order to help support mental transformations that occur on a bodily level.

1 2 3 4 5

g) Rehearsal of stress inducing or potentially triggering situations in the


therapeutic session to help prepare patient for real situations.

1 2 3 4 5

h) The use of touches and massage to elicit a trusting relationship between


therapist and patient.

1 2 3 4 5
Repairing the Broken Mirror 66

i) Synchronous breathing between therapist and patient, a dyad of patients or


group of patients.

1 2 3 4 5

j) Having patients roll, lay, etc. on the floor to explore tactile sensations in order
to improve body boundaries.

1 2 3 4 5

k) Exploration of weight utilizing polarities of pushing and pulling either alone or


with a partner.

1 2 3 4 5

Are there any specific techniques/interventions that you have developed and utilized that
have proven themselves effective? If yes, please explain:

11) To what extent do you use transference in the treatment of this population? Please
rate according to the following scale:

1 2 3 4 5
never use use moderately use all the time

Please describe how you utilize transference of the patient in treatment.

12) To what extent do you use countertransference in the treatment of this population?
Please rate according to the following scale:

1 2 3 4 5
never use use moderately use all the time

Please describe how you use your countertransference in the treatment of this population.

13) To what extent does working with women suffering from bulimia nervosa affect your
own sense of body-self and body image? Please rate according to the following scale.

1 2 3 4 5
never rarely sometimes more than most of the
often time
Repairing the Broken Mirror 67

14) If this work does affect your body-self and body image, please describe in what ways
it is experienced.

15) Of the following, what methods do you utilize to promote self-preservation? Please
rate from 1 to 12 with 1 being the most important and 12 the least.

- Personal Therapy
- One on one supervision
- Peer supervision
- Group supervision
- Massage therapy
- Authentic movement
- Dance classes
- Yoga
- Martial arts
- Meditation
- Exercise
- Other please provide details:
Repairing the Broken Mirror 68

Appendix B

Recruitment Email

Dear ________,

As a current Master’s candidate in Dance/Movement Therapy at Pratt Institute in

New York, I am conducting research on women suffering from Bulimia Nervosa

as part of my thesis project. I am currently recruiting ADTR’s and other

accredited therapists primarily using movement, with at least 5 years experience

working with this population, to participate in my study. Participation in this

study would include the completion of a questionnaire (completion will take no

more than one hour) including questions on movement qualities, the evaluation of

specific interventions and self-care. Participation might also include a semi-

structured interview to clarify responses to questionnaire and expand on topics of

interest, not to exceed thirty (30) minutes. This interview would be done at the

discretion of the principal investigator via phone or in person depending on

location and availability. Participation in this study is completely voluntary and

no remuneration will be provided. The data being collected will serve to create a

comprehensive treatment manual for dance/movement therapists working with

women suffering from Bulimia nervosa. If you are interested in participation

please respond to this email and I will send you the necessary information to

make an informed decision about participating or not.

Thank you for you time and consideration

Ariele Riboh
Repairing the Broken Mirror 69

Appendix C

Pratt Institute
200 Willoughby Avenue Brooklyn, NY 11205

CONSENT TO PARTICIPATE IN A RESEARCH STUDY

TITLE OF STUDY: Repairing the Broken Mirror: a Theoretical Dance/Movement


Therapy Manual for the Treatment of Women with Bulimia.

RESEARCH STUDY:

I, __________________________________________, have been asked to


participate in a research study under the direction of Ariele Riboh
(Dance/Movement Therapy student - Masters candidate at Pratt Institute).

PURPOSE:

The purpose of this study is to establish a more comprehensive understanding of


eating disorders and characteristics in order to establish more effective modes of
treatment through dance/movement therapy interventions.

DURATION:

Participation in this study will last for no more than 2 hours.

PROCEDURES:

During the course of this study, the following will occur:

• Completion of a questionnaire.
• A 30 minute semi-structured interview

PARTICIPANTS:

There will be 4 to 8 participants this research.

EXCLUSIONS:

I will inform the researcher if any of the following apply to me:


- I am under 18 years of age.
- I have not worked with eating disordered populations.
Repairing the Broken Mirror 70

- I am not a registered dance/movement therapist (ADTR) or licensed creative


art therapist (LCAT) or a credentialed therapist utilizing movement specific
interventions.
- I do not have at least 5 years experience working with this population.

RISK/DISCOMFORTS:

I have been told that the study described above appears to involve no risks or
discomforts known at this time. However there may be risks and discomforts that
are not yet known.

I fully recognize that there are risks that I may be exposed to by volunteering in
this study which are inherent in participating in any study; I understand that I am
not covered by Pratt Institute’s insurance policy for any injury or loss I might
sustain in the course of participating in the study.

CONFIDENTIALITY:

Every effort will be made to maintain the confidentiality of my study records.


Officials of Pratt will be allowed to inspect sections of my research records
related to this study. If the findings from the study are published, I will not be
identified by name. My identity will remain confidential unless law requires
disclosure.

PAYMENT FOR PARTICIPATION:

I have been told that I will receive $____0_____ compensation for my


participation in this study.

RIGHT TO REFUSE OR WITHDRAW:

I understand that my participation is voluntary and I may refuse to participate, or


may discontinue my participation at any time with no adverse consequences. I
also understand that the investigator has the right to withdraw me from the
study at any time.

INDIVIDUAL TO CONTACT:

If I have any questions about my treatment or research procedures I may discuss


them with the principal investigator:

Ariele Riboh, Masters candidate


(608) 345-0002 or ed.databank@gmail.com.

If I have any additional questions about my rights as a research subject, I may


contact:
Repairing the Broken Mirror 71

Vladimir Briller, Ed.D. Chair, IRB (718) 399-4245

SIGNATURE OF PARTICIPANT

I have read this entire form, or it has been read to me, and I understand it
completely. All of my questions regarding this form or this study have been
answered to my complete satisfaction. I agree to participate in this research
study.

Subject Name: ____________________

Signature: __________________________

Date: __________

SIGNATURE OF INVESTIGATOR OR RESPONSIBLE INDIVIDUAL

To the best of my knowledge, the participant,


______________________________, has understood the entire content of the
above consent form, and comprehends the study. The participant’s questions
have been accurately answered to his/her/their complete satisfaction.

Investigator’s Name: ____________________ Signature:


_______________________

Date: ______________
Repairing the Broken Mirror 72

Appendix D

Semi-Structured Interview Text.

These are potential questions that will be used to guide the interview. However the
interview will not be limited to these exact questions. Further questions will be
potentially used for further clarification and exploration of topics that may arise during
the interview.

1) What has your experience been like working with women with bulimia nervosa?

2) Over the years how have you dealt with issues of transference and
countertransference?

3) What methods of self-care do you utilize for self-preservation and to avoid burnout?

4) Given your answers on the questionnaire could you please further explain the
following intervention?

5) What is your goal for treatment when utilizing this specific intervention?

6) How do the patients respond to this intervention?


Repairing the Broken Mirror 73

Appendix E

Table 1

Answers to Questionnaire Concerning DMT Experience of Participants

Question Participant A Participant B Participant C Participant D

1. What are your Registered MA, ADTR, ADTR, LCAT MPS, ADTR,

professional clinical NCC (Licensed ATR-BC,

qualifications? counselor, (National Creative Art LCAT

ADTR, RDT Certified Therapist)

(Drama Counselor)

therapy)

2. How many years 18 17 10 Not answered

have you worked

with women

diagnosed with

bulimia nervosa?

3. Informing Object Chace, Modern Psychoanalytic,

theories? relations, Sullivan, Jung analytic feminist

bioenergetics, perspective,

attachment Chace,

theory, Whitehouse

Jungian, and and Evans

sensori-motor.
Repairing the Broken Mirror 74

Question Participant A Participant B Participant C Participant D

4. Goals 1 (not applicable) 2 (slightly relevant) 3 (relevant)

4 (moderately relevant) 5 (extremely relevant)

a) Reducing of 5 5 5 5

binge / purging

behaviors

b) Reduction of 5 5 3 4

body image

distortion

c) Increasing self- 5 5 5 5

esteem

d) Improving self 5 5 4 5

regulation

e) Developing 5 5 4 5

better coping skills

f) Increasing sense 5 5 5 5

of body self

g) Increasing body 5 5 3 4

boundaries

h) Increasing 5 5 4 3

spontaneity of

movement
Repairing the Broken Mirror 75

Question Participant A Participant B Participant C Participant D

Other: Increase Experience Understanding Increased

pleasure and feelings- one’s creativity and

comfort in connecting relationship to play.

body, help with the inner food and

manage stress, self, eating,

increase ability expressing increasing

to manage feelings, bodily

relationships, identifying understanding.

increase and

communication understanding

skills. connection

between

discoveries in

treatment and

applicability

in day to day

life.
Repairing the Broken Mirror 76

Question Participant A Participant B Participant C Participant D

5. Themes 1 (never) 2 (rarely) 3 (sometimes) 4 (often) 5 (all the time)

a) Control 5 5 4 5

b) Depression 4 5 5 5

c) Anxiety 5 5 4 5

d) Shame 5 5 5 5

e) Obsessive 4 5 3 5

thinking

f) Obsessive 4 5 2 5

behaviors

g) Sexual trauma 4 5 3 4

Other: Dissociation, Fear of Trauma such Inability to

attachment loosing as neglect, experience

issues, control. violence. Self- pleasure.

developmental hatred, self-

trauma, shock doubt, social

trauma and pressure to be

grief-loss. thin.
Repairing the Broken Mirror 77

Question Participant A Participant B Participant C Participant D

6. Movement 1 (strongly disagree) 2 (disagree) 3 (neither agree nor disagree)

patterns 4 (agree) 5 (strongly agree)

a) Purge position 4 Responses 3 3

considered

N/A

b) Lack of 5 N/A 4 3

movement in chest

c) Rigidity of 5 N/A 4 3

pelvis

d) Primary 5 N/A 4 5

utilization of

peripheral

movements

e) Difficulty 5 N/A 2 5

grounding weight

f) Indirect use of 4 N/A 4 3

space

g) Sporadic stop 3 N/A 4 3

and go movements
Repairing the Broken Mirror 78

Question Participant A Participant B Participant C Participant D

7. Other movement Lack of Explosive Minimal Decreased

patterns: integration movements. movements in lack of body

between upper near reach experience,

and lower space, a lack inability to use

body, agitated of full efforts. body

urgency or experience to

little sense of guide

time, focused actions/choice

directional s/thoughts.

movement,

poor spatial

awareness,

rigid spine,

lack of energy

and connection

to pelvis.
Repairing the Broken Mirror 79

Question Participant A Participant B Participant C Participant D

8. Interventions 1 (never use) 2 3 (use moderately) 4 5 (use all the time)

a) Guided imagery 3 1 3 3

b) Centering 5 5 2 4

exercises

c) Relaxation 5 5 2 4

techniques

d) Improvisation 4 5 4 3

e) Authentic 2 1 5 2

movement

f) Bartenieff 2 1 1 1

fundamentals

g) Props 4 4 2 1

9. Other Grounding, Participant Mirroring. Use of basic

interventions used: body chose not to stretching

awareness, respond exercises to

breath work increase

and boundary awareness of

work. body

experience.
Repairing the Broken Mirror 80

Question Participant A Participant B Participant C Participant D

10. Effectiveness 1 (not effective) 2 (somewhat effective)

of movement 3 (never use/not applicable) 4 (effective) 5 (extremely effective)

interventions

a) Exaggeration of 3 Participant 3 1

disliked body part chose not to

respond

b) Self touch 3 2 3 4

c) Chairs and body 4 2 3 3

image distortion

d) Freeze, red 4 1 3 3

light/green light

e) Physicalization 5 5 5 3

f) Functional 3 1 5 5

technique

g) Rehearsal 4 2 3 4

h) Touch and 3 1 3 5

massage

i) Synchronous 4 2 3 3

breathing

j) Floor work 4 2 3 3

k) Polarities 4 3 3 2
Repairing the Broken Mirror 81

Question Participant A Participant B Participant C Participant D

Other Sculpting Participant Mirroring, Focusing

interventions: feeling states, chose not to walking based

moving in respond meditation, exercises, use

relationship to stretching. of movement

emotions and phrasing.

cognitions,

exploration of

kinesphere

through body

and

visualization.

11. Use of 1 (never use) 2 3 (use moderately) 4 5 (use all the time)

transference

Scores: 5 5 4 N/A

Other: Transference Explores Used to Didn’t use due

provides therapeutically support to short-term

diagnostic actively and client’s setting

information, passively. process.

guides

interventions.
Repairing the Broken Mirror 82

Question Participant A Participant B Participant C Participant D

12. Use of 1 (never use) 2 3 (use moderately) 4 5 (use all the time)

countertransference

Scores: 4 Participant 4 5

chose not to

respond

Other: Also provides Participant Gather To understand

information chose not to information: metaphors of

about client. respond what does the the patient’s

client want me experience

to know? and to

Used to understand

understand the useful and non

client’s useful

experience. responses

within the

therapeutic

relationship.

13. Effect of work 1 (never) 2 (rarely) 3 (sometimes)

on body–self and 4 (more than often) 5 (most of the time)

body image

Scores: 4 2 3 3
Repairing the Broken Mirror 83

Question Participant A Participant B Participant C Participant D

14. What effects? Awareness of Participant More aware of Eating used as

effects on self chose not to personal a defense is

of cultural respond relationship to heightened.

images of food and

beauty eating.

Awareness of

cultural ideals

of beauty on

self.

15. Methods used Personal One on one Personal Personal

for self- therapy, one- supervision, therapy, one- therapy, one

preservation on-one peer on-one on one

supervision, supervision, supervision, supervision,

massages group group group

therapy, supervision, supervision, supervision,

authentic personal meditation, meditation,

movement, therapy. authentic exercise.

meditation, and movement,

exercise. social life.