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A comparative study of the dream content of eating-disordered and non-eating-disordered women Brink, Susan Goldswain 1991

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A C O M P A R A T I V E S T U D Y O F T H E D R E A M C O N T E N T O F EATING-DISORDERED A N D NON-EATING-D ISORDERED W O M E N BY S U S A N GOLDSWAIN BRINK B.A., The University of Cape Town, 1974. A THESIS SUBMITTED IN PARTIAL FULF ILLMENT O F T H E R E Q U I R E M E N T S FOR T H E D E G R E E O F MASTER O F ARTS in T H E F A C U L T Y O F G R A D U A T E STUDIES (Department of Counselling Psychology) We accept this thesis as conforming to the required standard T H E UNIVERSITY O F BRITISH COLUMB IA April 1991 © S u s a n Goldswain Brink, 1991 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of Co(~t^eitiiM> PsMCJMS/g The University of British Columbia Vancouver, Canada DE-6 (2/88) ii ABSTRACT Dream theorists propose that dreams can balance conscious reality, and provide clues to unconscious processes complicating psychosomatic conditions. Little research has been done in the area of dreams and eating disorders. Based on data from a pilot study, and reports of eating-disordered women's dreams in the literature, the researcher hypothesised that eating-disordered women's dreams would contain a significant number of themes symbolizing the psychological states underlying their condition. Of particular interest was a sense of ineffectiveness, which has been the subject of many recent studies of eating-disordered women. The exploratory study compared the dream content of 12 eating-disordered and 11 normal women, aged 20 to 35 years. The 275 dreams were rated by 8 "blind" raters according to a 91-item eating disorder specific dream rating scale, which registered dream content such as attitudes of helplessness, images of anger, self-hate, and affect. A high level of inter-rater reliability was obtained. A questionnaire assessing motivational states (General Causality Orientation Scale; G C O S ) was also administered. The data were analyzed by the independent t-test. The results showed strong significance in the occurrence of themes of ineffectiveness in the eating-disordered women's dreams (Q = .001), which corresponded with the findings on the G C O S (p. < .001). Also significantly present in the target group's dreams were themes of self-hate, anger, inability to nourish themselves, an obsession with weight, and the presence of negative emotions. An additional finding was a strongly significant presence of a sense of impending doom at the end of eating-disordered women's dreams (p. < .001). These results suggest that dreams may provide an additional resource in understanding eating disorders. iii TABLE OF CONTENTS Abstract ii Table of Contents iii List of Tables vi Acknowledgements vii Chapter 1: Introduction 1 Significance of the Study 1 Dreams 3 Definition of Terms 3 Chapter 2: Review of the Literature .7 Dreams as a Means of Healing 7 Studies of Dreams 8 Reports of Dreams of Eating-Disordered Women 12 Eating Disorders 14 Autonomy Disturbances in Eating-Disorders 20 Summary 25 Critique of previous research 26 Hypotheses 29 Chapter 3: Methodology 30 Purpose 30 Design .'..30 Procedure 31 Data analysis 36 Measures 37 iv Chapter 4: Results 41 Overview of the Data Analysis 41 Test of Dream Rating Scale Items 42 Test of the Hypotheses 45 Subject Profiles 45 Summary of Results 48 Chapter 5: Discussion 49 Summary of the Results 49 Interpretation of the Results 49 Hypothesis 1 49 Hypothesis 2 58 Theoretical Implications of the Dream Findings 62 Suggestions for Further Research 67 Summary 68 References -70 Appendices Appendix A. Formulation of Dream Scale 79 Appendix B. Hypothesis Categories 82 Appendix C. Dream Rating Scale 84 Appendix D. Recruitment Letter to Therapists 93 Appendix E. Volunteer Information 94 Appendix F. Volunteer Advertisement 95 Appendix G. Letter to Volunteers 96 Appendix H. Dream Logs 97 Appendix I. Pre-data Collection Interview 98 V Appendix J . Consent form and Consent Receipt 99 Appendix K. Standardised Telephone Conversation 101 Appendix L. Introductory Paragraph to Questionnaires 102 Appendix M. Instructions to Raters 103 Appendix N. General Causality Orientation Scale 106 Appendix O. Hopkins Symptom Check List 122 Appendix P. Eating Attitude Test 124 Appendix Q. Means and Standard Deviations Across Groups for Items 1-90 on Dream Rating Scale 126 Appendix R. Subject Profiles for Eating-Disordered and Normal Groups 131 Appendix S. Dreams of Eating-disordered Women Suggesting Unmet needs in Infancy 134 Appendix T. Proposed Changes to Dream Rating Scale ...136 vi LIST OF TABLES Table 3.1: Mean Age and Frequency Distributions Across Groups: Eating-Disordered (ED) and Normal 34 Table 4.1: Means and Standard Deviations Across Groups for Statistically Significant Items on the Dream Rating Scale 43 Table 4.2: Means and Standard Deviations Across Groups for Item Combinations (Hypotheses) 46 Table 4.3: Means and Standard Deviations Across Groups for Questionnaires 47 vii ACKNOWLEDGEMENTS This study has been the biggest undertaking of my life to date. I could not have completed it without the guidance, support, and encouragement of a number of people, to whom I am extremely grateful. My particular thanks go to the members of my committee: Dr. Ishu Ishiyama, who did his best to mould me into a research writer; Dr. John Allan, without whose generous donation of time, expertise, and creative inspiration, finding a workable channel for my ideas would have been a daunting task; Dr. Harold Ratzlaff, who remained convinced through my darkest hours that dreams could be statistically analyzed, and gave unstintingly of his time and expertise; and Dr. Elliot Goldner, who was of great assistance in the recruitment process, and offered many valuable suggestions throughout the process of the study. I also thank Lori Rodway, for her invaluable assistance in setting up the paper, and the students and professionals who generously donated their time to rate the dreams. To my family and friends, who have encouraged and supported me throughout this time, I offer my special thanks. I am particularly grateful to my husband, Bernie, for his countless hours of help, and my children, Simon and Catherine, who have suffered the trials and tribulations of the long birthing process of this, my third child, with remarkable equanimity. Lastly, I would like to thank the women volunteers who entrusted me with the privilege of sharing their inner world. I was enriched by the process, and deeply moved by the courage of the eating-disordered women in their struggle to rise above the difficulties of their condition. 1 CHAPTER 1 This study was a comparative survey of the dreams of eating-disordered and normal subjects, to ascertain whether there is a significant difference in thematic content between the two groups. The term "eating disorder" was used in this context to include both or either anorexia nervosa and bulimia nervosa. The term "normal" was used to describe subjects judged to be free from an eating-disorder. Since eating-disorders are a primarily female affliction, with only 8.6% of anorexics estimated to be male (Lucas, Beard, O'Fallon, & Curland, 1988), the feminine pronoun has been used in referring to the literature. Significance of the study Anorexic and bulimic women present a difficult and sometimes intractable problem to therapists. The physical consequences of entrenchment of the disorder are severe, with a mortality rate of anywhere between 2% to 2 1 % amongst anorexics (Steinhausen & Glanville, 1983). Psychologically, these women lead diminished lives. Their maladaptive eating behaviours and obsessive rituals form a major focus of their daily experience, with commensurate impoverishment of their interpersonal relationships. Yet they generally exhibit a strong resistance to giving up the anorexic/bulimic stance (Crisp, 1980). Wooley and Wooley (1985) state that body image distortions, which they see as the core issue in eating disorders, are extremely resistant to change by conventional therapeutic techniques. Wooley and Wooley understand body-image distortion as resulting from dysfunctional family dynamics, as well as socio-cultural 2 factors. Bruch (1973) is of the opinion that traumatic interpersonal experiences in early life are the cause of a distorted and grotesque self-image in adolescence. Chernin (1985) believes that at the heart of each woman's body-image problem is a struggle between wanting an identity separate from the mother and being overcome with "survivor guilt" if she succeeds. Chernin sees the manifestation of this struggle, namely an obsession with food and weight, as symbolic of the insatiable "hunger" of the deprived inner self. Therapists currently treating body-image disturbances in eating-disorders (Hutchinson, 1985; Orbach, 1982; Woodman, 1982; Wooley & Wooley, 1985) advocate the value of creative techniques that utilize unconscious processes. Visualization, art therapy, and movement, seem to be effective in getting women to go beneath the surface obsession with food and weight. Wooley and Wooley state that these indirect methods have often proved more effective in accessing forgotten aspects of body image than direct methods of therapy. Data from a preliminary pilot study of the dreams of five eating-disordered women, collected in an in-hospital program (Brink, Allan & Ishiyama, 1987), found the patients to be more willing to explore their dreams than to discuss their feelings and concerns directly. The researchers understood the apparent lack of resistance to dream work as based in a perception of dreams as being outside of personal issues, and therefore non-threatening. Brink et al. found six themes prevalent in the dreams of the patients which seemed to symbolize some of the underlying psychological processes of eating-disorders. Examination of the data from the pilot study (Brink et al., 1987) raised two questions: (a) does the dream content of eating-disordered women differ significantly from the dream content of non eating-disordered women in specific 3 themes? and (b) might dreams represent a means to utilize unconscious processes in eating disorders? The present study addresses the first question. Dreams Hall and van de Castle (1966) have defined dreams as visual experiences which occur during sleep. Dreams have alternately been called hallucinations. projections (Hall, 1966), and perfectly accurate thoughts (Freud, 1900/1938). Dreams, as they are commonly known, are actually dream reports. This is the only way of knowing dreams, yet dream reports are verbal descriptions of primarily visual experiences in which much may be lost (Hall & van de Castle, 1966). Hall and van de Castle liken the dream to a poem from the unconscious, and like poetry, it takes many forms, from "...lightening impressions to endlessly spun out dream-narrative" (Jung, 1948/1974b, p 81). Definition of terms In this study, the following terms have been given the ascribed meaning: Anorexia nervosa. Self-starvation resulting from a driving preoccupation with thinness. Diagnostic criteria for anorexia nervosa are (American Psychiatric Association, 1987): (a) Refusal to maintain body weight over a minimal normal weight for age and height, e.g. weight loss leading to maintenance of body weight at 1 5 % below that expected; or failure to make expected weight gain during period of growth, leading to body weight 1 5 % below that expected; (b) intense fear of gaining weight or becoming fat, even though underweight; (c) disturbance in the way in which one's body weight, size, or shape is experienced, e.g. the person claims to "feel fat" even when emaciated, believes that one area of the body is "too fat" 4 which one's body weight, size, or shape is experienced, e.g. the person claims to "feel fat" even when emaciated, believes that one area of the body is "too fat" even when obviously underweight; (d) in females, absence of at least three consecutive menstrual cycles when otherwise expected to occur (primary or secondary amenorrhea), (p. 67) Anorexia nervosa was judged to be present in this study by the clinical diagnosis of the attending therapist. Past research in anorexia nervosa (Toner, Garfinkel, & Garner, 1986; Vandereycken & Pierloot, 1983) has divided the disorder into subtypes of "restrictive anorexia" and "anorexia with bulimia", but this study has not been concerned with the differences. All subtypes have been considered as anorexia nervosa, and have been grouped together with bulimia under the classification of eating disorder. The terms "anorexia" and "anorexia nervosa" have been used interchangeably throughout the paper. Anorexic. An individual suffering from anorexia nervosa. Bulimia Nervosa. The literal meaning of bulimia is "ox hunger", from the Greek "bous", meaning ox, and "limos", meaning hunger (Geddie, 1970). Bulimia Nervosa means a drive of psychogenic origin to ingest, and subsequently purge the body, of large amounts of food. This is usually done in secret or inconspicuously. The diagnostic criteria for bulimia nervosa are (American Psychiatric Association, 1987): (a) Recurrent episodes of binge eating (rapid consumption of a large amount of food in a discreet period of time); (b) a feeling of lack of control over eating behavior during eating binges; (c) the person regularly engages in either self-induced vomiting, use of laxatives or diuretics, strict dieting or fasting, or vigorous exercise in order to prevent weight gain; (d) a minimum of two binge eating episodes a week for at least three months; (e) persistent overconcern with body shape and weight, (pp. 68-69) For ease of writing, the term "bulimia" has been used to indicate bulimia nervosa. Bulimic. An individual suffering from bulimia nervosa. Dreams. Visual experiences occurring during sleep which are "... spontaneous self-portrayal(s) in symbolic form, of the actual situation in the unconscious" 5 (Samuels, Shorter, & Plant, 1986, p. 48). The term "dream" signifies a dream report. Eating disorder. This subclass of disorders is characterized by gross disturbances in eating behavior; it includes Anorexia Nervosa, Bulimia Nervosa, Pica, and Rumination Disorder of Infancy. Anorexia Nervosa and Bulimia Nervosa are apparently related disorders, typically beginning in adolescence or early adult life. (American Psychiatric Association, 1987, p 65) In this study, the term "eating disorder" means anorexia nervosa and/or bulimia nervosa. Helplessness. Without ability to do things for oneself (Geddie, 1970). In this study "helplessness" has been taken to mean feeling as if one is unable to take action. Helplessness has been used interchangeably with a sense of  ineffectiveness and low perceived self-efficacy. Negative Emotions. Feelings that are unpleasant or upsetting in some way; that detract from enjoyment. Normal subjects. Women of the stipulated age, drawn from the community. -Criteria for inclusion in the normal group were: (a) a score below 30 on the Eating Attitudes Test (EAT, Garner & Garfinkel, 1979), to control for eating-disordered symptoms associated with a driving preoccupation with thinness; and (b) scores lower than the mean of the eating-disordered group on at least three out of the five subscales of the Hopkins Symptom Checklist (HSCL, Derogatis, Lipman, Rickels, Uhlenhuth, & Covi, 1974), to control for psychosomatic disorders. Psychosomatic disorders. Minuchin, Roseman and Baker (1978) differentiate psychosomatic conditions into primary and secondary categories: (a) "primary" indicates an established physiological condition exacerbated by emotional arousal, 6 and (b) "secondary" indicates the transformation of emotional stress into physical symptoms, in the absence of a predisposing physical condition. Anorexia and bulimia fall into the secondary classification. Self-efficacy. Efficacy is the power of producing an effect (Geddie, 1970). Perceived self-efficacy is the judgement of how well one can execute courses of action required to deal with prospective situations (Bandura, 1982). Low perceived  self-efficacy is the judgement that one will poorly execute the courses of action required, and be unable to deal effectively with prospective situations. Low  perceived self-efficacy has been used interchangeably with helplessness, and a. sense of ineffectiveness. The theoretical literature of dreams and eating disorders are reviewed in the following chapter. 7 CHAPTER 2: REVIEW OF LITERATURE Dreams as a Means of Healing The idea of dreams as a tool for psychiatric healing was introduced into modern medicine at the turn of the century by the Viennese psychiatrist, Sigmund Freud (Arlow, 1984). Freud understood dreams as disguised expressions of the dreamer's wishes, needs and fears. Freud's one-time associate, C. G. Jung, made the research of dreams a major focus of his life work, and his findings led him to conclude that dreams are the way the psyche balances the conscious reality of the dreamer, and in so doing offer a path to healing (Samuels, 1985). He stated that "... the dream shows the inner truth and reality of the patient as it really is: not as I conjecture it to be, and not as he would like it to be, but as it is" (Jung, 1934/1970, p. 57). Jung's view of dreams as representing psychic facts conflicted with Freud's view of dreams as repressed instinctual drives, and ultimately led to an irreconcilable split between these two major figures of the early psychoanalytic movement (Jung, 1961). Since Jung's time, many dream therapists have concurred with his view (Faraday, 1972; Rossi, 1985; Sanford, 1978; Ullman & Zimmerman, 1979), seeing dreams as healing images containing honest information about disowned or unfamiliar parts of the self. Weizsacker (1937) studied the dreams of women suffering from anorexia nervosa. He found themes of the state of the body interwoven with images and occurrences suggesting contemporary, historical, cultural or intellectual issues. He suggested that these strands weave together into an artistic whole which he calls the "myth" of the dream (Weizsacker, 1964). He concluded from his studies that 8 the dream is an intermediary between somatic issues and consciousness. Sabini (1981) seems to be in agreement with Weizsacker's view, proposing that dreams offer a unique assessment tool of the unconscious processes complicating psychosomatic illnesses, as well as unconscious resistances to treatment. Studies of Dreams Biela (1986) researched "breakthrough" dreams (i.e. problem solving dreams) for the purpose of finding the individual meaning of the dream experience for each of her seven subjects. She approached the study phenomenologically, using individual interviews to explore common patterns in the immediate and long-term after effects of the breakthrough dream experience. Thirty common themes in the experience prior to, during, and after the dream were isolated. Ten common themes were found within the dream experience. Alexander and Wilson (1935, cited in Hall & van de Castle, 1966) studied the dreams of 18 patients with gastrointestinal disturbances, which were then classified according to Alexander's theory of pregenital impulses. The results of the study were seen as supporting the clinical understanding of gastrointestinal cases. Patients suffering from constipation were found to have more retentive dreams, whereas those with peptic ulcers had more dreams of passive receiving and aggressive taking. Those with chronic diarrhoea scored highest in passive receiving. Despite the fact that the researchers experienced scoring difficulties, such as differentiating between images of retentive behaviour and inhibited giving, and having to resort to free association to clarify some ambiguities, Hall and van de 9 Castle (1966) consider the study to be ground-breaking in the field of content analysis of dreams. Beck and Hurvich (1959, cited in Hall and van de Castle, 1966) combined a theoretical and empirical approach to formulate a scale measuring masochism in dreams. The content of several hundred dreams of depressed and non-depressed women were studied for the presence of images indicating a need to suffer. Three categories, each with several subcategories of possible thematic content, were formulated, and two investigators practised scoring with the manual until 9 5 % reliability was obtained. Beck and Hurvich then compared the first 20 dreams from a group of depressed women with the same number of dreams from a group of non-depressed women, using the masochism scale. Their hypothesis, that a significantly higher incidence of masochism would be present in the depressed women's dream content, was confirmed. Cann and Donderi (1986) studied the relation between personality type and the recall of everyday dreams versus archetypal dreams, in 146 non-clinical subjects. The researchers used Hall and van de Castle's (1966) criteria for scoring number of words, setting, characters and affect in the dreams; and Kluger's 7-point scale (1975, cited in Cann & Donderi, 1986) for scoring rationality and "everydayness". Independent raters were used with inter-rater reliability tests done on a random sample of dreams. The results showed significant correlations between certain Jungian personality types and the nature of the dream content. Garfield (1987) studied the nightmares of 13 sexually abused teenagers. She analyzed the dream content by identifying themes, characters, objects and emotions in each of the dreams, which were then counted and given an overall percentage rating. No control group was used. Four common themes were found: 10 (a) secrecy; (b) helplessness; (c) terror; and (d) entrapment and accommodation; which Garfield linked to the underlying psychological responses to sexual abuse. Recorded emotions were guilt, shame and hatred. Levitan (1979, 1981a, 1981b) researched the role of dreams in psychosomatic complaints and came to the conclusion that certain thematic content may correlate to the psychology of the specific psychosomatic illness. He identified three dream types in eating-disorders, based on his study of six anorexic women's dreams (Levitan, 1981a): (a) dreams of violence where the dreamer is the aggressor; (b) dreams of violence where the dreamer is the victim; and (c) incestuous dreams. Weizsacker (1937) studied the dreams of two hospitalized anorexic women, focusing on the differences between the dreams preceding a restrictive period and those preceding a bulimic period. What he found in common in all the dreams was a "...quality of floating between life and death, and the painful contradiction of the patients' feelings vis-a-vis their closest relatives" (Weizsacker, 1937 p. 191). He cites one dream as an example of the inner tension of narcissism, where the neurotic constantly believes she is being watched and persecuted: I am standing and around me are heaped provisions and food which I must eat. I am very unhappy about it because all around me there are eyes, nothing but eyes, eyes watching how I will eat. A pair of eyes changes into the face of my brother, how he snickers, mean and ornery, (p. 191) Weizsacker believes that it is this tension, this anxious guarding of secrets, that feeds paranoid development, and exacerbates the symptoms of the neurotic patient. He sees the external battle with food that so often takes place in these families, as a reflection of the inner battle within the patient between the psyche and the body. 11 Dippel et al. (1987) studied sleep and dream patterns in 19 eating-disordered (ten anorexic; nine bulimic) and 16 depressed patients. Aspects of dream structure and dream content, including dream length, bizarreness, mood tone and feelings, self-assessment, body reference, and activities and interactions, were registered on a 70-item scale . Differences between (a) the depressive and the eating-disordered group, and (b) the anorexic and the bulimic subgroups, were calculated. Patients with eating disorders were found to dream of food in 4 4 % of their dreams, while the depressed patients had no food images in their dreams. Bulimic patients had a higher incidence of negative affect in their dreams, with more frequent incidents of hostile acts towards the dreamer, and 3 2 % more occurrences of food than were found in the dreams of the anorexic group. Fourteen dreams collected from five eating-disordered women, during the course of an in-hospital program, were analyzed by the researchers for similarity in thematic content (Brink et al., 1987). Six themes were isolated, and were given to independent student raters for verification. The six themes were: (a) dreamer out of control of a frightening situation; (b) dreamer attempting to change the frightening situation to no effect; (c) entrapment; (d) violence; (e) difficulty taking in nourishment; and (f) fragmentation. The images of violence either represented the dreamer as the victim, or dream figures as victims. There were no dreams where the dreamer was the perpetrator of violence. Emotions expressed in the dream reports were panic, terror, fear, shock, helplessness and sadness. Brink et al. (1987) concluded that the six themes indicated some of the unconscious dynamics in eating-disordered women's lives. 12 Reports of Dreams of Eating-Disordered Women Binswanger (1958) noted very vivid dreams with themes of food and death, in the dreams of anorexic "Ellen West". The themes of food show the dreamer (a) being extremely hungry, yet only eating very small portions, (b) being unable to get food, (c) overeating on rich foods immediately prior to death, or (d) in the process of dying. Themes of death are either (a) suicidal (dreamer asking to be shot, or wanting to set herself on fire), or (b) approaching certain death with joyous expectation. Woodman (1982) has found images of blocked, plugged, or overflowing toilets to be prevalent in the dreams of eating-disordered women, as well as inaccessible toilets, or toilets with strange and unlikely contents. She understands this type of toilet dream as symbolizing the blocked emotional expression so typical of anorexic and bulimic women. She also talks of images of weak wraiths and an ethereal sense of being released from the grave, which she understands as signifying the "weightless" state of the anorexic. Images of weightlessness and spirituality could also be understood as the anorexic obsession with asceticism noted by Bruch (1978): "I felt I had to do something for a higher purpose....my body became the visual symbol of pure ascetic...everything became very intense and very intellectual, but absolutely untouchable." (p. 17) Weizsacker (1937) found dreams of exultation and bliss, with themes of spirituality and redemption, prior to anorexic periods in his two patients. Similar to Binswanger (1958), dreams of fading away and death were connected to periods of overeating. Meyer and Weinroth (1957, cited in Spignesi, 1983) describe patients as associating eating with sinfulness, and starvation with saintly virtue. 13 Selvini-Palazzoli (1963/1974) does not see the anorexic renunciation of the body as a spiritual choice. Nor does she see it as an unconscious death wish. She understands the acarnality of the anorexic as a "... rejection of death as a biological fact, and with it a rejection of aging, corpulence and existential decay" (p.81). Selvini-Palazzoli has found her anorexic patients to play with death like children, who "disappear" by pretending to die, which she understands as a refusal to engage in any kind of interpersonal relationship. Dreams of anorexics cited by Selvini-Palazzoli (1963/74) contain images of helplessness; a sense of being continually watched "...but Mother could see my every move..." (p.64); images of food in hostile, inaccessible places, such as a poulterer's store being a large, very cold, refrigerator, where the chickens had to be put in display cases, each guarded by penguins with sharp beaks; and seemingly overpowering images, such as the "...hideous, frightening and enormous..." (p. 65) penguin guards, with accompanying emotions of fear and terror. Unlike Levitan (1981a), Selvini-Palazzoli found no evidence of active aggression in her patients' dreams. She understands this from an object-relations viewpoint, namely that the body of the incipient anorexic does not merely contain the negative, overpowering aspects of her mother, but in fact becomes the bad object itself. At an unconscious level, the anorexic experiences this reified body as too strong to be destroyed. Woodman (1982) writes of dreams where the dreamer is a "thing", not a person, such as one woman's dream of herself as a golf-ball. Here can be seen the concept of self as "pawn", rather than "origin" (deCharms, 1968, cited in Deci and Ryan, 1985). The theme is one of helplessness. Reports of eating-disordered women's dream show images of violence, food, choking and suffocation, suicidal wishes, ethereal beings, and truncated arms and 14 legs. Food images show themes of aggression by food, unavailable, insufficient or inedible food, and gigantic portions of food, such as a dreamer eating a whole cow (Binswanger, 1958; Levitan, 1981a; Selvini-Palazzoli, 1963/1974; Thoma, 1967; Weizsacker, 1937). Pervading many of the dreams is an attitude of helplessness. Weizsacker (1937) interprets the need for secrecy and sense of being watched in his clients' dreams as evidence of paranoia and narcissism. Levitan (1981a, p. 228) observes that the dreams of his anorexic subjects reveal "...undisguised and unrestricted instinctual expression". Brink et al. (1987) found similar patterns of intense emotion in the dreams which contrasted with the flat affect the patients presented clinically. Jung proposed that dreams compensate conscious experience in this manner as a regulating psychic process, much like the compensatory mechanisms of the body (Jung, 1934/1970). Eating disorders History Anorexia nervosa as a medical condition of seemingly "nervous" origin, has been documented since 1689, although cases appear to have been rare until the early 20th century. By 1937, a German physician had noted as many as 50 cases of emaciation in girls of late puberty (Kylin, cited in Selvini-Palazzoli, 1963/1974). Anorexia nervosa does, however, appear to have been in existence many centuries before it was given a medical description. It is thought that the ancient physicians such as Hippocrates encountered voluntary starvation of a psychogenic origin (Selvini-Palazzoli, 1963/1974). The starving female saints of the Middle Ages, who in their day were understood as renouncing individual will to the higher will of God, 15 have been termed "holy anorexics" (Bell, 1985). Bell understands their "self-sacrifice" as an attempt to regain a sense of personal power, in reaction to the patriarchal control of the church. It took until the 1960s for anorexia nervosa to be clearly understood as a primarily psychiatric condition, mostly as a result of the increasing number of cases and the special study of the condition by psychiatrists such as Hilde Bruch and Peter Dally (Selvini-Palazzoli, 1963/1974). Bulimia nervosa has only recently emerged as a distinct clinical entity. Bulimic episodes have been noted as one of the symptoms of anorexia nervosa in many case histories, so much so that Bruch wrote in 1985 that she very much doubted it could be seen as a separate condition. However, the increased incidence of bulimic symptoms in the absence of restrictive dieting have led to studies of the difference in levels of psychological functioning between anorexics and bulimics (Garfinkel, Moldofsky & Garner, 1980; Casper, Eckert, Halmi, Goldberg, & Davis, 1980; Strober, 1980; Strober, 1981). Etiology Bruch (1982) discusses the disturbances in appropriate developmental tasks which interfere with the development of autonomy and initiative in the incipient anorexic. She sees these disturbances as originating in infancy in a basic trust/mistrust issue. She proposes that the mothers have been "out of sync" with their daughters' needs since early in the child's life. Stern (1977, cited in Turner,1980) terms these "...missteps in the dance..." (p. 10), which Turner (1980) views as laying the foundations for anorexia nervosa in adolescence. Turner also believes that if autonomous functioning is stunted in one phase, it is more likely to 16 show up again at a similar psychological stage, rather than in the next chronological stage. Hence the development of anorexia nervosa in adolescence, when the child is once again required to separate from parents. Girls who have been curtailed in autonomous functioning, learn to suppress independent thoughts and feelings, becoming obedient and conforming, with only a narrow range of emotional reactions (Bruch, 1982). Bruch states that anorexics "... feel helpless and ineffective in conducting their own lives, and the severe discipline over their bodies represents a desperate effort to ward off panic about being powerless" (1982, p. 1532). Miller (1979/1981) understands this development of mistrust as the basis of narcissism, which is rooted in the narcissistic parent's need to use the child as a way to bolster his or her own deprived sense of self. Narcissistic pathology has been specifically linked to bulimic pathology by Davis and Marsh (1986) in their case study of two bulimic adolescents. Levenkron (1982) disagrees with the view that the anorexic feels out of control of her environment. He claims that eating-disordered women of today come from homes where parents feel depleted. These young women have felt compelled to take care of their parents from an early age, with resultant deficiencies in their own development. It would appear that Levenkron's argument does not conflict with the psychoanalytic view, since the narcissistic parent does indeed feel depleted, and the dependence of the parent on the child may be overt or covert (Miller, 1979/1981). Cases studied by Minuchin et al. (1978) show the anorexic child to experience herself as both inefficacious to meet challenges from the outside world and inappropriately powerful in certain intrafamilial interactions. Minuchin et al (1978) isolated four characteristics of family functioning which seem to encourage somatization in the susceptible child: enmeshment, 17 overprotectiveness, rigidity, and lack of conflict resolution. They verified their theory by developing a standardized interview in which 45 families carried out a series of family tasks under observation. Conflict situations and intrafamily transactions were observed. In the "anorexagenic" family, Minuchin et al (1978) found the four family characteristics to result in Loyalty and protection [taking] precedence over autonomy and self-realization. A child growing up in an extremely enmeshed system learns to subordinate the self. Her expectation from a goal-directed activity, such as studying or learning a skill, is not therefore competence, but approval. The reward is not knowledge, but love. (p. 59) These are the types of families where initiative is seen as an act of betrayal (Minuchin et al, 1978). Boskind-White (1979) views the development of eating disorders from a feminist perspective. She is in agreement with the view that a sense of autonomy is poorly defined in anorexics and bulimics, and that these women perceive themselves in terms of a role, rather than as individuals, with a resulting loss of a core sense of self. However, she does not see the cause as lying solely in the family, but also in cultural and social pressure. Boskind-White understands the predominance of attractive women in her practice as being rooted in an early social message that rewards are to be sought by means of physical attributes; that for females, internal qualities do not count. She has found that rejection in the dating arena often precipitates the initial dieting. For women who have been taught to define themselves in terms of being able to inspire and hold the love of a man, rejection is experienced as annihilation of self. The meaning of rejection is physical imperfection (Boskind-White, 1976). A poem written by an anorexic woman immediately after a broken engagement illustrates this perception (Binswanger, 1958): 18 Woe's me, Woe's me! The earth bears grain, But I Am unfruitful, A m discarded shell, Cracked, unusable, Worthless husk. Creator, Creator, Take me back! Create me a second time And create me better! (p. 247) Sheppy (1985) decided to examine both the family unit and the broader social implications in the etiology of anorexia nervosa. The eco-systemic study looked at the individual, the family, the parent-anorexic interactions, and the quality and size of the social network. The instruments used measured interpersonal characteristics and styles important for social living and social interaction; interpersonal behaviours, including self-concept qualities of the subjects and their parents; family environment; and the size and quality of the social network. Self-concept was examined in terms of the introjects from significant others. The findings by Sheppy (1985) showed significantly less cohesion in anorexic families, and mothers of anorexics to have significantly higher scores on the psychopathic deviancy scale than mothers of controls. This scale measures passive aggression. Anorexics were found to experience their mothers as significantly more controlling and less affiliative than controls, and to feel significantly less affiliation toward their parents. Anorexics were also found to have higher levels of depression, anxiety, and hostility than normal subjects. No significant differences were found in the size and quality of social networks of anorexic versus control families. Sheppy (1985) also found the low affiliation scores in the anorexic daughters, and the higher psychopathic deviancy scores in the mothers of anorexics, gave the 19 highest hit-rate in discriminating anorexic from non-anorexic subjects. Since the hit-rate did not decrease with the removal of the psychopathic deviancy variable, Sheppy proposed that the characteristics of the anorexic individual are the major predisposing factor in the development of anorexia nervosa. The question arises whether the failure to find significant differences in hit-rates with many of the variables might not be due to the fact that Sheppy used families from a medical setting as controls, as opposed to obtaining subjects from a more "normal" setting. Of particular interest to this study were Sheppy's (1985) findings concerning the expression of hostility in anorexics. Anorexics were found to turn their anger inward in the form of guilt and self-punitive behaviour and thoughts, rather than expressing it outwardly. Clinicians such as Goodsit (1985) have noted how anorexics disavow their anger, whilst displaying it in body language and passive-aggressive actions, such as the very act of starvation, which Goodsit sees as an unconscious punishment of the parents. Perera (1986) writes of the fear of aggression that develops in the child of narcissistic parents, resulting in denial of her self-protective assertion, and increasing feelings of worthlessness and guilt at being unable to live up to her parents projected ideals. The legitimate rage of the "scapegoated" child becomes "split off' from consciousness, so that she experiences herself as helpless and needy, while outwardly appearing manipulative and demanding. Crisp (1980) sees the ability of families to permit their daughters "...not only to live but to be..." (p. 49), as crucial to the development of a sense of self worth and an intact social sense of self. He sees parental social and psychological resources, the spousal relationship, and the meaning of the existence of the particular child in the family, as crucial in the developmental process of the said child. Drawings by 20 Crisp's anorexic patients (Crisp, 1980) reflect themes of (a) the self as a fragmented object, (b) being engulfed, (c) isolation, (d) intense feelings smothered by a layer of blackness, (e) rootlessness, and (f) abandonment. Etiological theories of eating-disorders seem to suggest that the sense of self in the pre-anorexic/bulimic child develops in a fragile and peripheral way. Since she does not experience her strong will as positive and healthy power but as unacceptable aggression, the incipient anorexic/bulimic tries to suppress it in order to be accepted. The fact that it boils over sometimes in extreme stress serves only to reinforce her experience of herself as being unable to interact efficaciously in the world. Autonomy disturbances in eating disorders Studies McLaughlin, Karp and Herzog (1985) conducted a study to test Bruch's (1973) theory of a prevailing sense of ineffectiveness in patients with anorexia nervosa, and to investigate whether her model could be applied to patients with bulimia. Two measurements were used, a projective test and a self-report measure. The results were conflicting. The results from the Embedded Figures Test (EFT) supported Bruch's observations of anorexics, and show a sense of ineffectiveness to be a prevalent dynamic amongst bulimics as well. However, the self-report measure showed no significant difference in autonomy ratings between eating-disordered subjects and controls. The researchers understood this contradiction in findings as being due to the hazards of self-report. Strauss and Ryan (1987) studied disturbances in autonomy in subtypes of anorexia nervosa. They quote Bruch's definition of a low sense of autonomy as "...a struggle for control, for a sense of identity, competence and effectiveness" (Bruch, 1973, cited in Strauss & Ryan, 1987, p. 254). The authors see three major psychological manifestations emanating from these autonomy difficulties, namely "...distortions of body image, misperceptions of internal states, and most centrally, a paralysing sense of ineffectiveness" (Strauss & Ryan, 1987, p. 254). Subjects were divided into three categories, namely restrictive anorexics, anorexics with bulimia, and non-eating-disordered controls. After administering three self-report scales: the General Causality Orientations Scale (GCOS, Deci & Ryan, 1985b); the Structural Analysis of Social Behaviour (SASB); and the Family Environment Scale (FES), and a projective test, the Rorschach Mutuality of Autonomy Scale (MAS), the clearest significant difference between the three groups was observed in the restrictive anorexic group on the impersonal dimension of the G C O S . Both eating-disordered groups rated significantly higher than the control group in low autonomy projections on the MAS (p. = .001), and in intrapsychic autonomy on the SASB. Interpersonal autonomy on the SASB showed no differences. Wagner, Halmi, and Maguire (1987) used a locus of control scale, a self-efficacy scale, and the E F T to test a personal sense of ineffectiveness in an adolescent eating-disordered group comprised of anorexics and bulimics. They found a social sense of confidence to be linked to a sense of confidence in food related behaviour in the control group, yet in the eating-disordered group, ineffectiveness in dealing with food appeared to be independent of a sense of ineffectiveness in other areas. Restrictive and bulimic anorexics exhibited the greatest sense of ineffectiveness in social and independence areas, with normal 22 weight bulimics comparing well with the controls in these areas. However, in the area of ineffectiveness with food, the eating-disordered subjects with bulimic symptoms demonstrated the highest sense of ineffectiveness, with the restrictive anorexics demonstrating the least. From these results, the researchers concluded that a sense of ineffectiveness in eating disorders may not be the global experience it appears to be in other subject groups. Theories Bandura (1982), in his study of perceived self-efficacy in human agency, specifies self-efficacy as the ability to persist at a task in the face of obstacles. Perceived self-efficacy "...refers to peoples' judgements of their capabilities to execute given levels of performance ... [and] ... affects the amount of effort devoted to a task" (O'Leary, 1985, p. 438). Studies have been conducted on the ability to overcome various types of addictive behaviours related to perceived self-efficacy ratings (O'Leary, 1985). O'Leary (1985) suggests that the treatment of eating disorders could benefit from such a study. Deci and Ryan (1985a) understand a sense of efficacy as emanating from intrinsic motivation, which is ...based in the innate, organismic need for competence and self-determination. [Intrinsic motivation]...energizes a wide variety of behaviors and psychological processes for which the primary rewards are the experiences of effectance and autonomy [underline added]", (p. 32) Deci and Ryan (1985a) see Bandura's (1982) lack of recognition of the intrinsic satisfaction of self-efficacy as a major flaw in his theory, and one that puts his view in a markedly different position from theirs. According to these authors, Bandura's 23 understanding of the effect of high perceived self-efficacy is not based in the associated intrinsic rewards, but in the attainment of reinforcements. Deci and Ryan (1985a) differentiate their view from Bandura's (1982) view by distinguishing between internally controlling standards and internally informational standards. An internally controlling standard is linked to the attainment of reinforcements. It may sustain behaviour until the standard is met, but it reduces subsequent intrinsic motivation, and increases anxiety and tension. An internally informational standard is associated with intrinsic rewards and maintains intrinsic motivation with a reduction of tension. Deci and Ryan find the concept of an external and internal locus of control (Rotter, 1966) does not take account of the differences in internal controls. In the light of Deci and Ryan's theory, the findings of a high sense of effectiveness in areas of food behaviour in restrictive anorexics, by Wagner et al. (1987), might be due to their use of Bandura's sense of self-efficacy, and Rotter's locus of control theory, which fail to discriminate between internal standards. Deci and Ryan (1985a) devised three causality orientations, namely autonomy, control,and impersonal, with the differentiating factor being choice. This is not the kind of 'choice' in which individuals feel they should or have to 'choose' a certain behaviour because of perceived social or familial expectations. The concept of choice in this model is motivational. Individuals with an impersonal orientation experience themselves as being incompetent to deal with life's challenges. They believe that behaviour and outcomes are independent, and that external forces are uncontrollable, with a resultant sense of helplessness. The impersonal orientation "...may lead people to behave without intentions [so that they] may engage in addictive behaviours and feel helpless in relation to them. In general, the impersonal orientation will be accompanied by a high level of anxiety..." (Deci & Ryan, 1985a, p. 60) and is characterized "...by feelings of ineffectiveness and helplessness" (Strauss & Ryan, 1987, p. 255). The individual who operates from a control orientation experiences initiating events as pressure to perform accordingly, without experiencing a real sense of choice. The controls determining this mode of functioning may be internal or in the environment. The autonomy orientation operates from an integrated sense of self, where the motivating factor is a need to be self-determining, rather than a need to control the environment. Deci and Ryan (1985a) state that "...[when] people are intrinsically motivated, they experience interest and enjoyment, they feel competent and self-determining, they perceive the locus of causality for their behaviour to be internal, and in some instances they experience flow" (p. 29). Cziksentmihalyi (1975, cited in Deci & Ryan) used the word "flow" to describe the emotion of true enjoyment. The antithesis of interest and flow is pressure and tension. Deci and Ryan (1985a) predicted that there would be a positive relationship between autonomy and self-esteem, no correlation between self-esteem and the control orientation, and the impersonal orientation would be negatively correlated with self-esteem. These predictions were substantiated. Garner, Rockert, Olmstead, Johnson, and Coscini (1985) have formulated a personality portrait of anorexics and bulimics from the results of several studies: Anorexic patients have been found to be obsessional, introverted, socially anxious, conscientious, perfectionistic, competitive, overcontrolled, socially dependent, shy, and 'neurotic' (Garfinkel & Garner, 1982; Garner, Olmstead, & Polivy, 1983; King, 1963; Solyom, Freeman, Thomas & Miles, 1983; Strober, 1980; cited in Garner et al, 1985, p. 561)... [whilst] most studies have found 25 bulimics to be impulsive, prone to addictive behaviours, emotionally turbulent, and depressed (Casper, Eckert, Halmi, Goldberg, & Davis, 1980; Garfinkel, Moldofsky, & Garner, 1980; Lacey, 1982; Strober, 1981; Strober, Salkin, Burroughs, & Morrell, 1982; cited in Garner et al, 1985, p. 561) The perfectionistic component of the eating disorder "personality" manifests itself in an "...all or nothing kind of reasoning, and the setting of unattainable goals" (Anderson, Morse, & Santmyer, 1985, p. 327). These personality traits suggest that anorexic and bulimic women would likely fall into the two externally focused orientations, namely the control orientation and the impersonal orientation. More specifically, since low self-esteem is common to both groups (Baird & Sights, 1986), it could be presumed that both bulimics and anorexics would score highest in the impersonal orientation. However, Strauss and Ryan (1987) found restrictive anorexics to score significantly higher on the impersonal orientation scale of the G C O S than bulimics and controls. They concluded from their findings that "...a pervasive sense of ineffectiveness seemed uniquely characteristic of the restricters" (Strauss & Ryan, 1987, p. 257). Summary Life themes for eating-disordered individuals would therefore appear to be: (a) a pervasive sense of being out of control of themselves and their environment, whilst being overcontrolled by others, particularly family; (b) the presence of anger, which is repressed and turned inward self-destructively; (c) a fragmented and peripheral sense of self; (d) an inability to nurture themselves, only feeling worthwhile if they give to others; (e) difficulty expressing feelings; (f) the invasion of privacy by family members; and (g) a sense of being continually watched and judged by others. 26 These themes are manifested in obsessive/compulsive thoughts and behaviours to do with food and weight, and a pronounced need to please. The literature seems to suggest the presence of these life themes and obsessions in the documented dreams of eating-disordered clients (Binswanger, 1958; Brink et al., 1987; Levitan, 1981a; Selvini-Palazzoli, 1963/1974; Sours, 1980; Thoma, 1967; Weizsacker, 1937; Woodman, 1982). The question therefore arose as to whether these themes would have a significantly higher occurrence in the dreams of an anorexic and bulimic population, compared with a non eating-disordered population. Critique of previous research Dreams of women with eating disorders, (Levitan, 1981a; Selvini-Palazzoli, 1963/1974; Sours, 1980; Thoma, 1967; Weizsacker, 1934; Woodman, 1982, 1985a, 1985b) have been interpreted in various ways according to each writer's theoretical orientation. Levitan, Sours, and Thoma have approached the dreams from a psychoanalytic perspective, seeing repressed aggressive and incestuous wishes in the dream content. An example is the repetitive dream of an anorexic, cited by Sours where the dreamer is swimming in a lagoon, anxiously watching for her father, convinced that she can only escape if he pulls her out. He interprets the dream as involving a great deal of sexual feelings towards the father. The perspective of analytical psychology sees archetypal themes where the psychoanalytic theorists might use sexual interpretations, such as symbols of disintegrating foundations or collapsing tunnels implying a loss of connection with archetypal ground, with the "Great Mother" (Woodman, 1982). Woodman 27 understands the archetype of the Great Mother as the creative and spiritual feminine nature which is constant, enduring and wise. The feminine nature of the pre-anorexic or bulimic girl is experienced as solely lodged in her body and her accomplishments (Boskind-White, 1976\1979; Miller, 1979; Chernin, 1985; Woodman, 1982, 1985a, 1985b) and therefore subject to destruction by perceived ugliness, aging, and failure. Selvini-Palazzoli (1963/1974) and Weizsacker (1937) appear to have responded to their patients' experience of the dream, rather than using theoretical interpretations, thus taking an existential and phenomenological approach to dream interpretation. The dreams recorded by the psychoanalytic researchers can also be understood according to the themes suggested by Brink et al. (1987). For example, a dream that Levitan (1981a) interprets as repressed incestuous wishes towards the father, can be seen to fit into several of the proposed categories. Father is holding me down...we are having actual intercourse...! am blindfolded but the blindfold slips...it really is him...I am struggling and screaming...Finally I wake up. (p. 230) The dreamer appears to be trapped: "father is holding me down"; she is also attempting to effect a change in the situation without success: "I am struggling and screaming"; and she is being aggressed against, namely raped. The dream does not portray willing consent to the sexual act, but rather fear of and entrapment by the father figure. Intercourse in the dream appears to symbolise violence rather than desire. The dream cited by Sours on the previous page can also be understood as demonstrating a sense of helplessness. There is scant information to be found in the literature on the statistical analysis of eating-disordered women's dreams. Dippel et al. (1987) used a 70 item standardized rating manual to compare the dreams of anorexic, bulimic and depressive patients. Differences in dream content were indicated by using the chi square test. Levitan (1981a) used a simple frequency distribution when examining the dreams of anorexics in a bulimic phase. Dreams falling into one of the three categories occurred in an average of 4 1 % of the six subjects' dreams. He did not have a clear rating scale, neither did he check his ratings with outside raters. He makes assumptions from his theoretical viewpoint which he states as facts without substantiation, such as interpreting the dream of rape by the father as repressed incestuous wishes. The present study has attempted to be as free of theoretical bias as possible in the formulation of dream category titles. Thematic interpretation of dream images, emotions, attitudes and behaviours was descriptive, avoiding theoretical terms such as paranoia, narcissism, and enmeshment. A combined theoretical and empirical approach was used to formulate the dream rating scale, using the etiological theories of eating-disorders (Bruch, 1973, 1978, 1981, 1982; Crisp, 1980; Minuchin et al., 1978; Selvini- Palazzoli, 1963/1974; Sheppy, 1985) and data from dreams reported in the literature (see Appendix A for details). Because the scope of dreams is immense, and the images a dreamer produces in the dream specific to her experience (Faraday, 1972; Ullman & Zimmerman, 1979), the dream scale used in this study was not expected to cover all the possible images and behaviours representative of the underlying psychological states of eating disorders. The study has sought to provide a carefully controlled scoring system with independent raters to guard against the possibility of the type of subjectivity evident in Levitan's study (1981a). Studies of the dreams of anorexic and bulimic women to date have not used normal controls (Dippel et al., 1987; Levitan, 1981a; Weizsacker, 1937). The use of normal controls therefore has provided normative data to allow a meaningful comparison, which has been a neglected methodological element in previous dream research of eating-disordered populations. Hypotheses Hypothesis 1: The dreams reported by eating-disordered subjects will have a significantly higher incidence of the following manifested psychological themes, than the dreams reported by normal subjects (see Appendix B for dream content indicating the presence of the psychological themes): 1.1. low perceived self-efficacy 1.2. anger 1.3. self-hate 1.4. a fragmented sense of self 1.5. a sense of being rigidly controlled 1.6. a sense of invasion of privacy 1.7. a sense of being watched and judged by others 1.8. an inability to self-nourish/self-nurture 1.9. blocked emotions 1.10. an obsession with food 1.11. an obsession with weight Hypothesis 2: The dreams reported by eating-disordered subjects will have a significantly higher incidence of negative emotions than the dreams reported by normal subjects. CHAPTER 3: METHODOLOGY. 30 Purpose The purpose of the study was to look for the presence of specified dream content in the dreams of eating-disordered women, and to ascertain whether the specified categorical incidents were significantly different in an eating-disordered group than in the dreams of a normal group. The information obtained should provide data for further research in the usefulness of dream-related therapy for eating-disordered women. Design The study was designed as survey research with two subject groups, namely (a) a psychosomatic group (women diagnosed as having an eating disorder; ED), and (b) a normal group (women who did not suffer from an eating disorder; Non-ED). Dreams from both groups of subjects ( £ s ) were collected over a 4 week period and analyzed by several independent raters according to the absence, presence, or extreme presence of specific themes. The independent t-test was used to test for statistical significance of the occurrence of the dream content between the two groups. Thematic Approach to Dream Analysis Dreams in this study were divided into four thematic categories to facilitate rating. The categories were (a) attitudes, (b) behaviours, (c) emotions, and (d) images; see Appendix C for Dream Rating Scale. 31 Attitudes. An attitude is understood as the individual belief system which affects how a significant event is acted upon (Ellis, 1984). An example of an attitude is the belief "whatever I do I won't succeed". Actions in dreams were taken as indications of the motivating belief system of the dreamer; see Appendix A for formulation of Dream Rating Scale. Behaviours. A behaviour is any type of action performed by one of the dream figures in the dream. Prior to commencing data collection, specific behaviours were isolated as possibly connected to the underlying dynamics in eating-disorders; see Appendices A and B. Emotions. Specific emotions were looked for in the dreams; see Appendices A and B. These emotions were not presumed from the dream story, but were only taken as present if stated by the dreamer. Images. Images are dream pictures, such as images of blood, violence, or ethereal beings. Jung and von Franz (1964) understand an image as a sign from the unconscious, by means of which symbolic understanding of the dream is possible. Rossi (1985) sees dream images as representative of an emotional state. In this study, specific images were linked to pre-established psychological themes; see Appendix B. Procedure Recruitment and Screening Criteria Volunteers were informed that this was to be a study of the dreams of women from different backgrounds. The psychosomatic population under survey was women between the ages of 15 and 35 years, suffering from an eating disorder (as diagnosed by their attending therapist according to DSM-111-R criteria). The non-psychosomatic control group consisted of women of the same age group, judged to be free of an eating disorder (i.e., scoring less than 30 on the E A T scale, and scoring less than the mean score of the psychosomatic group on 3 out of the 5 subscales of the HSCL). The ED sample was obtained first, and an assessment was made about where and how to recruit the Non-ED subjects so as to match age, socio-economic status, and education, as closely as possible. The ED sample was drawn from Vancouver, Canada, and Bellingham, U.S.A. Therapy practices, in-patient eating disorder programs from three Vancouver hospitals, and a Vancouver support group were approached by letter for subjects (Appendix D). Handouts were included for possible volunteers giving information regarding the time commitment, confidentiality, and rewards for participation (Appendix E). All eating-disordered volunteers satisfying the criteria were used. The Non-ED sample was recruited via an advertisement in two suburban newspapers (Appendix F), and two university psychology classes at the third year level. Respondents were questioned as to age, occupation, education, and the presence/absence of a psychiatric illness. This question was prefaced by the researcher stating that she needed to check on group membership. Those who matched the eating-disordered volunteers were asked to participate in the study and an interview time was set up. The remaining volunteers were informed that a random sample was to be drawn from the people who had volunteered, and if they were drawn, they would be contacted for an interview. After the interview time was set up, each £ was sent a letter (Appendix G) and several dream logs (Appendix H) to begin recording dreams as practice for the study. The S_s were instructed to 33 bring the dream logs to the interview. This was to check for ability to recall and record dreams. These dreams were not used as data for the study. Subjects The £ s were 23 females between the ages of 20 and 35 years. Of the 12 anorexic and bulimic women, four came from an in-patient program in a Vancouver hospital, four from a Vancouver psychiatric practice, and the remaining four from therapy practices in Vancouver and Bellingham. Eleven of the thirteen Non-ED S_s selected were included in the study, as two were disqualified after rating beyond the cut-off point on the E A T scale (Garner & Garfinkel, 1979). A number of demographic characteristics are summarized in Table 3.1 to describe the women in the two groups. A close match in age was obtained between the two groups. The Non-ED group was somewhat higher in level of education than the ED group, and showed greater stability in marriage and occupational status. The pre-data collection interview. A uniform interview format was used for both groups of Ss to control against different pre-data collection experience affecting dream material (Appendix I). The consent form was signed prior to commencement of the interview (Appendix J). Anonymity and confidentiality were again stressed to control against selective dream recall, and allay anxiety. Data collection. Data collection commenced immediately after the interview. S s were given dream logs, a subject number of their choice, and a manila envelope in which to store their dream logs. Each £ was telephoned at weekly intervals to provide encouragement with the recording of dreams; see Appendix K for standard telephone conversation to control against influencing dream recall. At the end of Table 3.1: Mean (Aoe) and Frequency Distribution Across Groups:  Eating-Disordered (ED) and Normal (hi) Variable ED Non-ED (n=12) (n=11) Age (yr) 24.33 25.08 Marital Status Single 9 9 Common-law 1 1 Married 1 2 Divorced 1 0 Education High School 6 4 College 3 1 University 3 6 Occupational Status Employed 4 8 Unemployed 3 0 Student 3 3 Sickleave . - ' 2 0 four weeks the researcher called each § to inform her that the data collection period was complete, and to set up a time for the debriefing interview. Debriefing interview. One week after the end of the dream data collection period, each S spent approximately 90 minutes terminating their participation in the study. This involved 30 minutes to fill in three questionnaires (HSCL; G C O S ; & EAT), followed by an hour with the researcher to debrief the experience of participating in the study, and work with any dream or dreams of particular interest or concern. The three questionnaires were given in counter-balanced order. The questionnaire package was introduced by a paragraph reminding Ss of their right to withdraw from the study at any time (Appendix L). Anonymity of Dream Material. All names and other identifying data in the dreams were changed in both subject groups. This was of particular importance where images indicated subject group identity. For example, if the dreamer talked about being in hospital, this was changed to a boarding house, university residence, or prison, depending on the context; "therapy groups" were changed to "women's groups"; professional titles such as doctor and nurse were deleted. If the deletions were thought to change the meaning of the dream content, substitutions were used; for example, "doctor" in one eating-disordered subject's dream was changed to "authority figure". Utmost care was taken to ensure that the substitutions maintained the meaning of the dream story. A total of 11 out of the 139 dreams in the ED group were changed in this manner. In addition, subjects had been requested to include identifying explanations in their dreams, such as "N (mv cousin)". This was so that an amplified meaning could be gleaned from the dream reports. An example of how these amplifications were used is the changing of "H, (an anorexic patient in the hospital)" into "H, a very thin girl" in the dream 36 reports. Only data relevant to the dream scale were used. A total of 5 dreams out of the 139 dreams of the ED group were changed in this manner, with no changes required in the Non-ED group. Raters. There were eight independent raters, four volunteers from the graduate student population of counselling psychology, and four volunteers from a "Jung" study group. All of the raters were working as therapists, either full-time or part-time, and four of them used dream work as part of their therapeutic method. The raters were given a six hour instruction period prior to commencing the rating (see Appendix M for instructions to raters). There were 275 dreams collected, 139 from the ED group, and 136 from the Non-Ed group. Each rater was given approximately 33 dreams and was "blind" as to the group membership of the dreamer. Thirty-one dreams were randomly selected from the rated dreams of both groups, and given to one of the trained raters. The ratings were then compared with the ratings from the first round, and a percentage agreement over the first 90 scores was obtained by dividing the numbers of scores in agreement by 90, and multiplying by 100. Score 91 was treated separately since the format was somewhat different from the preceding 90 scores. Reliability for items 1 to 90 was very high and was reflected by a 93.3% to 100% agreement between raters. Agreement in item 91 was also high at 83%. Data analysis The dreams of each £ were analyzed by rating the absence, presence, or extreme presence of items 1 - 90 on the dream rating scale (Appendix C). "Absent" (A) carried a value of zero, "present" (P) a value of one, and "extremely present" 37 (EP) a value of two. Item 91 assessed the ending of the dream: "resolution" scored zero; "left open-ended" scored one; and "a sense of impending doom" scored two. Every S's total for each item was divided by the S_'s number of dreams to obtain a proportion (i.e. decimal value). For example, S_ E's scores: Item A(xO) PfxD EP(x2) No. of dreams score 1. 11 1 0 12 1/12 = 0.08 2. 12 0 0 12 0/12 = 0.0 3. 10 2 0 12 2/12 = 0.16 4. 12 0 0 12 0/12 = 0.0 5. 12 0 0 12 0/12 = 0.0 6. 10 1 0 12 3/12 = 0.25 . 12 12 91. 4 6 8 12 16/12 = 1.33 The £ s were divided into their respective groups (i.e., ED & Non-ED), and a mean obtained for each item. The individual items were tested for significance using the t-test for independent groups. The item means for each of the two groups were then combined in a pre-determined order under the appropriate hypothesis heading (see Appendix B). The means for the two S groups were calculated for each hypothesized category (H.1.1. - H.1.11., and H.2.). These were then tested for significance using the t-test for independent groups. The mean for each group's score on the pencil and paper tests were also tested for significance using the independent t-test. Measures General Causality Orientations Scale (GCOS: Deci & Ryan. 1985b). The G C O S was chosen because the theoretical underpinnings of the three measured orientations appear to best fit the attitudes being examined in this study. The scale (Appendix N) measures the motivational states, termed "causality orientations" (Deci and Ryan, 1985a), governing the individual's behaviour. The three orientations, which correspond to the three subscales of the General Causality Orientations Scale, are: Autonomy ("A"), Control ("C"), and Impersonal ("I"). The scale consists "...of 12 vignettes depicting interpersonal and achievement-related situations. Each is followed by three items, one representing each of three causality orientations. The resulting 36 items are rated along a 7-point Likert scale indicating the degree to which the subject would endorse each motivational orientation" (Strauss & Ryan, 1987, p. 255). Deci and Ryan (1985b) rated subscale internal consistency as satisfactory, with alpha equalling .70 to .76. Test-retest reliability was also satisfactory, with alpha equalling .71 to .78. Construct validity was supported by meaningful correlations with eleven other personality measures, including a depression scale (Beck & Beamesderfer.1974, cited in Deci & Ryan, 1985a), a self-esteem scale (Janis & Field, 1959, cited in Deci & Ryan, 1985a), and Rotter's Locus of Control Scale (1966). Hopkins Symptom Check List (HSCL: Derogatis et al. 1974). This is a 58-item self-report checklist, out of which 45 items of high item total correlation were extracted (Appendix O). The check list measures the psychological symptoms of somatization, depression, obsessive-compulsive tendencies, interpersonal sensitivity, and anxiety (Derogatis, et al, 1974). Neurotic symptoms are rated on a 4-point Likert scale ranging from "'not at all"' to "extremely distressful". The Hopkins Symptom Check List is reported to have item-total correlations ranging from r = 0.45 to r = 0.80, and high internal consistency for each neurotic dimension (ranging from r = 0.84 to r = 0.87). Garner and Garfinkel (1980) examined socio-cultural factors in the development of anorexia nervosa by using 39 the H S C L in conjunction with the E A T when comparing samples of professional ballet students, models, and normal university students. Eating Attitudes Test (EAT: Garner & Garfinkel. 1979). The E A T (Appendix P) is a 40-item scale, designed to measure a broad spectrum of symptoms characterizing anorexia nervosa, including bingeing and purging behaviours. The E A T was cross-validated between two independent groups of anorexic subjects versus normal controls. According to Garner & Garfinkel (1979), a high level of validity was obtained (r = 0.87). The alpha reliability coefficient was estimated at 0.79 for the anorexic subjects, and 0.94 for the pooled sample of anorexic and normal £ s (Garner & Garfinkel, 1979). Obese female subjects scored significantly lower on the E A T than anorexic females, suggesting that the measure is specifically sensitive to eating disorders that relentlessly pursue thinness. The E A T was tested on recovered anorexics, who scored in the normal range. The scale has thus been found to be sensitive to clinical remission. Garner and Garfinkel (1980) used the E A T in conjunction with the H S C L in certain of their subsamples, and found that psychological symptoms were positively correlated with E A T scores. For the group at high cultural risk to develop anorexia nervosa (i.e., ballet dancers and models), and for the group with previously diagnosed anorexia nervosa, the correlations were 0.41 and 0.53 respectively. Dream Rating Scale. The 91-item dream scale (Appendix C) was formulated by combining the etiological theories of eating-disorders (Bruch, 1973,1978,1981, 1982; Crisp, 1980; Minuchin et al., 1978; Selvini- Palazzoli, 1963/1974; Sheppy, 1985) with corresponding images, behaviours, emotions and attitudes found in eating-disordered women's dreams (J. Allan, personal communication, August, 1987, through March, 1988). The dream content used to formulate the categories of the dream scale was limited to dream material from the literature on eating disorders, and raw data from a pilot study of eating-disordered women's dreams. The system of classification used was specific to eating disorders. The scale was tested on a student rater three consecutive times to check for ease of rating and comprehensibility of the items. Appendix A gives details of the formulation of the individual categories. CHAPTER 4: RESULTS 41 This chapter overviews the data analysis, records and tabulates the statistically significant findings for the Dream Rating Scale, and records the subject profiles as measured by the self-report tests. Overview of the Data Analysis The mean scores for each group (ED & Non-ED) on all of the four measures (Dream Rating Scale; G C O S ; HSCL; EAT) were tested for statistically significant differences by means of the independent t-test. Items on the dream rating scale were then grouped together according to predetermined groupings (Appendix B) to test the hypotheses. The independent t-test was again used. Each group registered 91 mean scores on the Dream Rating Scale; three mean scores on the G C O S ; five mean scores on the HSCL; and one mean score on the EAT. The hypotheses represented eleven combined mean scores from the Dream Rating Scale for each group. The independent t-test was used on each of the 111 mean scores, and all results registering probability at .10 level and lower, were taken as statistically significant. The .10 probability level was chosen for the following reasons: (a) that the survey is of an exploratory nature, with little established research in the area; and (b) that a type 11 error could mean a loss of possible significant data, whereas the criticalness of a type 1 error would not have serious consequences for the groups under examination (i.e., ED & Non-ED). However, because multiple comparisons were being performed, with the resultant liberalization of alpha, caution needs to be exercised in interpretation. Results 42 showing probability levels of .001 and less can be understood as clear indications of significant differences. Test of Dream Rating Scale Items The total number of dreams collected equalled 275, of which 139 belonged to the ED group, and 136 to the Non-ED group. Under the category of attitudes (first three items), all mean scores were significantly higher for ED dreams (Table 4.1). The attitudes were: 1. Whatever I do I won't succeed (t = 3.30, p. < .005). 2. I may succeed, but change seems so slow I remain anxious and discouraged (t = 1.72, Q = .10). 3.1 can only succeed if somebody helps me ( i = 1.75, Q < .10). Under the category of behaviours (items four to seven), the mean score for item number four, "struggling and/or screaming with no change being effected", was significantly higher for the dreams of the ED group than for the Non-ED group, as recorded in Table 4.1. There were no significant differences in the remaining three scores for behaviours. Under the category of emotions (items eight to forty-nine), four mean scores were significantly higher for the dreams of the ED group than for the Non-ED group (Table 4.1): 1. Anger (t = 1.95, Q < .08). 2. Feeling exposed or vulnerable (t = 2.18, p. < .05). 3. Guilt (t = 2.42, p < .05). 4. Feeling unloved (t = 1.90, p_ < .08). There were no significant differences in the remaining 37 scores for emotions. Table 4.1: Means (M) and Standard Deviations (SD) Across Groups  for Statistically Significant Items on the Dream Scale Item on Dream Scale ED (n-12) Non-ED (n-11) t-value P Attitudes 1. Whatever I do I M 0.39 0.05 3.30 .003 won't succeed SD 0.32 0.08 2. I may succeed but M 0.09 0.03 1.72 .101 change is slow etc. SD 0.10 0.06 3. I can only succeed M 0.21 0.05 1.75 .095 if someone helps SD 0.30 0.07 Behaviors 4. Struggling/screaming M 0.21 0.02 2.04 .054 to no effect SD 0.31 0.04 Emotions 8. Anger M 0.36 0.15 1.95 .065 SD 0.32 0.17 20. Exposed/vulnerable M 0.03 0.00 2.18 .041 SD 0.04 0.00 25. Guilt M 0.10 0.02 2.42 .025 SD 0.10 0.04 48. Unloved M 0.05 0.00 1.90 .071 SD 0.09 0.00 Images 50. Imprisonment M 0.07 0.00 2.29 .032 SD 0.10 0.00 54. Being held against M 0.08 0.00 1.92 .069 will SD 0.13 0.00 55. Being forced to M 0.07 0.01 1.97 .062 do something SD 0.10 0.03 74. Very thin people M 0.09 0.00 2.11 .047 SD 0.15 0.00 75. Negative reaction M 0.06 0.00 2.19 .040 to weight gain SD 0.10 0.00 78. Being watched as if M 0.15 0.02 2.55 .019 guilty/Inadequate SD 0.15 0.06 83. Being chased with M 0.06 0.01 1.67 .111 no escape SD 0.09 0.02 84. Being attacked M 0.26 0.03 3.25 .004 SD 0.23 0.05 Endinq 91. Sense of threat M 1.37 0.81 5.06 <.001 SD 0.31 0.20 44 Under the category of images (items 50 to 90), eight mean scores were significantly higher for the dreams of the ED group than for the Non-ED group (Table 4.1). The significant images were: 1. Imprisonment/captivity of dreamer (p = 2.29, p < .05). 2. Dreamer being forcibly held and not let go (p = 1.92, p < .07). 3. Dreamer being made to do something against will, not involving being held by force (t = 1.97, p < .07). 4. Very thin people (t = 2.11, p < .05). 5. Dreamer/dream figure having a negative reaction to weight gain (t = 2.19, p < .05). 6. Being watched as if guilty of something, or of being inadequate (t = 2.55, p < .02). 7. Being chased with no obvious escape (t = 1.67, p .10). 8. Dreamer being attacked by person, animal, or thing (t = 3.25, Q < .005). There were no statistically significant differences in the remaining 32 scores for images. Item 91 assessed the nature of the ending of the dream, whether it contained a sense of resolution (scoring zero), left the dream open-ended (scoring one), or contained a sense of impending doom (scoring two). As recorded in Table 4.1, the ED mean score was significantly higher than the Non-ED (t = 5.06, p < .001). A detailed table of all the results of the Dream Rating Scale (items 1 - 90) can be found in Appendix Q. 45 Test of the Hypotheses Hypothesis 1.1 to 1.11. The scores of items 1 to 90 were grouped together in pre-determined combinations to test Hypothesis 1.1 to Hypothesis 1.11 (see Appendix B for details). As Table 4.2 shows, the means for the ED group were significantly higher than for the Non-ED group in five out of the eleven categories. The five categories were: 1. Low perceived self-efficacy (t = 3.72, p = .001). 2. The presence of anger (t = 2.59, p = < .05). 3. Self-hate (J = 3.36, p = < .005). 4. Inability to self-nourish/self-nurture (t = 2.80, p = .01). 5. An obsession with weight (t = 2.74, p = .01). The remaining six categories showed no statistically significant difference between the two groups. Hypothesis 2. It was hypothesized that there would be a significantly higher incidence of negative emotions (items 8 - 49) in the dreams of group one than in group two. This was confirmed (J = 3.10, p < .01), as shown in Table 4.2. Subject Profiles G C O S . The three subtests measured autonomy, control, and impersonal orientations respectively. As shown in Table 4.3, the ED mean was significantly lower than the Non-ED mean in the autonomy orientation (J = - 2.16, p < .05), and significantly higher than the Non-ED mean in the impersonal orientation (t = 4.93, p < .001). There was no significant difference between the two groups in the control orientation. Table 4.2: Means and Standard Deviations Across Groups for Item Combinations (Hypotheses) Hypotheses ED (n=12) Non-ED (n=11) t-value P Hypotheses 1 1.1 Low Perceived M 1.21 0.26 3.72 .001 Self-Efficacy SD 0.82 0.23 1.2 Anger M 0.96 0.42 2.59 .017 SD 0.62 0.32 1.3 Self-Hate M 0.55 0.19 3.36 .003 SD 0.32 0.16 1.4 Fragmented M 0.02 0.04 -0.63 .533 Sense of Self SD 0.05 0.07 1.5 Sense of being M 0.31 0.15 1.37 .185 Rigidly controlled SD 0.29 0.30 1.6 Invasion of M 0.07 0.07 0.04 .966 Privacy SD 0.09 0.12 1.7 Interpersonal M 0.20 0.09 1.42 .169 Sensitivity SD 0.19 0.17 1.8 Inability to M 0.16 0.05 2.80 .011 Self-nourish SD 0.12 0.07 1.9 Blocked M 0.01 0.02 -0.67 .510 Emotions SD 0.02 0.06 1.10 Obsession M 0.75 0.59 0.72 .490 with Food SD 0.64 0.37 1.11 Obsession with M 0.26 0.06 2.74 .012 Weight SD 0.23 0.08 Hypotheses II Negative Emotions M 2.43 1.57 3.10 .005 SD 0.53 0.78 Table 4.3: Means and Standard Deviations Across Groups  for the Three Questionnaires Name of Test/ Subtest ED (n-12) Non-ED (n-11) t-value P General Causality Orientation Scale Autonomy M 65.42 71.27 -2.16 <.050 SD 7.44 5.26 Control M 50.58 50.82 -0.06 .955 SD 12.80 4.73 Impersonal M 53.83 37.55 4.93 <.001 SD 8.09 7.71 Hopkins Symptom Checklist Somatics M 24.92 18.64 2.10 <.050 SD 9.12 4.08 Obsession M 20.00 13.73 2.70 <.020 SD 6.16 4.82 Interpersonal M 21.25 13.09 5.09 <.001 Sensitivity SD 4.43 3.05 Depresssion M 31.83 19.73 4.83 <.001 SD 7.77 3.07 Anxiety M 18.00 10.64 4.21 <.001 SD 5.56 1.69 Eating Attitude Test M 65.92 10.00 6.72 <001 SD 27.14 5.02 48 H S C L The five subtests measured somatic, obsessive, interpersonal sensitivity, depression, and anxiety symptoms respectively. As recorded in Table 4.3, the ED group scored significantly higher than the Non-ED group on all five subscales. The significant difference between the two groups tested at less than .05 probability for somatic symptoms, at .01 probability for obsessive symptoms, and at less than .001 probability for interpersonal sensitivity, depression, and anxiety. The marked presence of depression and anxiety in the ED group is in agreement with the findings by Sheppy (1985), in her examination of the anorexic individual. EAT. The E A T measured the absence or presence of a driving preoccupation with thinness. The ED group attained a clinically significant level of weight and shape preoccupation, while the Non-ED group showed little evidence of such a preoccupation (t = 6.72, p < .001). Profiles for both groups showing eating-disorder demographics, and individual scores on the EAT, the impersonal orientation of the G C O S , and the HSCL, can be found in Appendix R. Summary of the Results Significant differences were found between the two groups in important areas of both the projective material and the self-report tests. Several of the findings demonstrate similar personality traits found in previous studies of eating-disordered women (Lehman & Rodin, 1989; McLaughlin et al., 1985; Sheppy, 1985; Strauss & Ryan, 1987;) as well as in etiological theories of eating disorders (Bruch, 1973, 1978, 1981, 1982, 1985). The possible meaning and implications of the results are discussed in the following chapter. CHAPTER 5: DISCUSSION 49 This chapter interprets the results and discusses the implications. The hypotheses are evaluated, followed by a section on the possible theoretical implications of the findings from the dreams. Summary of the Results The results generally supported the two hypotheses, namely that there would be (a) significant differences in the occurrence of specific themes in the dream content of an eating-disordered (ED) group versus a normal (Non-ED) group (i.e., five out of eleven subcategories of hypothesis 1 were statistically significant), and (b) a significantly higher incidence of negative emotions reported in the dreams of the ED group. An additional finding was a significantly higher occurrence of the theme of impending doom in the endings of the dreams of the ED group than in the Non-Ed group. Dreams ending with a sense of impending doom had been noted in many of the eating-disordered dreams used to formulate the Dream Scale (Appendix A). Item 91 on the Dream Scale, which assessed how the dream ended, was included as a point of interest. Interpretation of the Results Hypothesis 1 1.1. Low Perceived Self-Efficacy. The question of primary interest in this survey has been whether the paralysingly low sense of perceived self-efficacy observed in anorexic and/or bulimic women (Bruch, 1982, 1985; Goodsit, 1985; McLaughlin et al., 1985; Schneider, O'Leary and Agras, 1987; Strauss & Ryan, 1987) would be significantly present in eating-disordered women's dreams. This was strongly supported, both at an individual item level for the attitude "whatever I do I won't succeed", and in the combined items (hypothesis 1.1). The levels of probability obtained from the projective material and the questionnaire in a sense of ineffectiveness in eating-disordered women, were very close. The present finding of a marked sense of ineffectiveness in eating-disordered women is compatible with the reports by other researchers (McLaughlin et al., 1985; Schneider et al., 1987; Strauss & Ryan, 1987). Schneider et al. (1987) found levels of perceived self-efficacy to be indicative of treatment outcome in a group of 14 bulimics, with an increased sense of self-efficacy occurring in five out of seven domains, during the course of cognitive-behavioral therapy to control vomiting. McLaughlin et al. (1985) found significant evidence of a sense of ineffectiveness in the projective material of both anorexics and bulimics. Strauss and Ryan's (1987) findings of a sense of ineffectiveness being limited to restrictive anorexics, lead them to conclude that a paralysing sense of ineffectiveness may be the definitive deficit of restrictive anorexia, with a higher level of affective and impulsive disorders as the protracting factor in bulimic disorders. Yet Bruch (1985) has noted that bulimics, although much more exhibitionistic and irresponsible than anorexics, act like "...completely helpless victims" (p. 12) once they have "learned" to binge and vomit. A sense of being a helpless victim has been taken to mean the presence of low perceived self-efficacy in this study. The question arises whether differences in perceived self-efficacy levels might have been found had the eating-disordered subjects in this study been subdivided into restrictive and bulimic groups. However, recent research appears to question the helpfulness of the divisions. Brouillette (1988), in a Rorschach assessment of the character structure of anorexic and bulimic female patients, found no significant differences in levels of psychological functioning between the groups. Brouillette states her study supports previous researchers' view that, despite certain differences, there is a core personality that is present across restrictive anorexics, bulimic anorexics, and bulimics (Strober, 1980; Norman & Herzog, 1983; cited in Brouillette, 1988). Results from the study of subgrouping in anorexia nervosa (Welch, Hall and Ross, 1990) suggest that divisions of eating-disordered women into groups of restrictive versus bulimic symptoms, are not helpful in determining eating-disorder psychopathology. This study, in support of previous studies, demonstrates that a sense of low perceived self-efficacy is a significant aspect of the anorexic and bulimic experience. Eating-disordered women's dreams can be seen to be informative of this psychological state. 1.2. Anger. Given the psychoanalytic theorists' view of the unconscious presence of anger in eating-disordered women's personalities (Bruch, 1982; Goodsit, 1985), and Jung's theory of the compensatory function of the psyche (Jung, 1934/1970; Samuels, 1985), the presence of anger in the unconscious material of the ED group was a second area of major interest in this study. It was significantly present in the dreams of the ED group, at the individual item level as well as the combined items for hypothesis 1.2 (see Appendix B for individual dream items indicating anger). This finding is in agreement with Levitan's (1981a) finding 52 of overt aggression in eating-disordered women's dreams, and in disagreement with Selvini-Palazzoli's (1963/1974) observation that there were no themes of active aggression in her anorexic patients' dreams. The confirmation of the hypothesis that anger would be significantly present in the ED group's dream material, seems supportive of dream theorists' view (Jung, 1934/1970; Rossi, 1985; Ullman & Zimmerman, 1979) that dreams present to the dreamer the unmasked truth of her experience. The results also support findings of a significant presence of hostility in anorexics by Sheppy (1985). 1.3. Self-Hate. The term "self-hate" was used for "anger turned inward", so as to delineate it from "anger", which were understood as two separate psychological experiences, albeit that self-hate has its origins in the primary emotion of anger. The significant presence of anger in its self-deflected form of self-hate was anticipated in the dreams of the ED group. As in hypothesis 1.2, this was based on (a) the psychoanalytic theorists' views on the presence of anger in eating-disordered women, which is "split off' from consciousness (Bruch, 1982; Goodsit, 1985) , and turned against the self in feelings of worthlessness and guilt (Perera, 1986) , and (b) Jung's theory of the compensatory function of dreams (Jung, 1934/1970; Samuels, 1985). The strong presence of self-hate in the ED group's dreams is in agreement with the findings of a significant presence of anger turned inward in anorexics by Sheppy (1985), and seems supportive of dream theorists' view (Jung, 1934/1970; Rossi, 1985; Ullman & Zimmerman, 1979) that dreams reveal the true state of the psyche to the dreamer. It would appear from the scores of both the individual and combined items of the Dream Scale, that anger is present more frequently in eating-disordered women 53 in it's self-deflected form of self-hate, than as primary anger, which is in agreement with the psychoanalytic view of eating disorders. Further dream research with a larger subject sample needs to be done to examine this concept further. 1.4. Fragmented Sense of Self. Eating-disordered women are understood by psychoanalytic theorists to be the products of narcissistic parenting (Bruch, 1973, 1978; Chernin, 1985; Goodsit, 1985; Perera, 1986; Spignesi, 1983). Such parenting results in deficits in ego-development, therefore images of ego-fragility were expected in eating-disordered women's dreams. Dream images of shattering glass, exploding bombs and collapsing foundations were taken as symbols of ego-fragmentation (see Appendix A for formulation of Dream Scale). No images of shattering glass were observed in either group in the study, with more images of exploding bombs appearing in the Non-ED group. The only item showing a higher incidence in the ED group was the image of disintegrating or collapsing foundations. Although this image occurred only in the dreams of the ED group, the difference was not significant. It would seem, however, that fragility and fragmentation are not synonymous; rather that ego fragility can lead to ego fragmentation, evidenced in psychosis. Certain clinicians see anorexia nervosa as a special defense structure between schizophrenia and depression (Selvini-Palazzoli, 1963/1974). The "shattering images" found in the dream material used to formulate the Dream Scale (Appendix A), came from two eating-disordered women with borderline personality disorders, both of whom were in crisis. Although psychologists working with personality disorders are of the opinion that most eating-disordered clients can be classified as such (I. Pechlaner, personal communication, 22nd January, 1991), it is possible that no eating-disordered subjects were in a state of ego fragmentation at the time of the study. It would appear that more research needs to be collected to establish accurate metaphors for ego fragility, a seemingly important aspect of the psychological experience of the eating-disordered woman. 1.5. A Sense of Being Rigidly Controlled. The lack of significance in the occurrence of a sense of being rigidly controlled in the dream material corresponds with the results in the control subscale on the G C O S . Research on a controlling environment as a factor in the etiology of eating disorders is mixed. Although Minuchin (1978) found that anorexic teenagers came from rigid and controlling homes, Sheppy (1985) did not find this to be a distinguishing feature in anorexagenic families. Root et al. (1986) have identified three types of families in bulimic disorders, with overly controlling behaviour a feature in two out of the three types, namely: (a) the "perfect" family, and (b) the "overprotective" family. In the third type, the "chaotic" family, the rules are haphazard and inconsistent. Root et al. are of the opinion that the third family type has received insufficient attention in the literature on eating disorders. Deci and Ryan (1985a) found no correlation between the control orientation and self-esteem, whereas the impersonal orientation was positively correlated with low self-esteem. It would therefore appear that a sense of being overcontrolled, with a subsequent need for control, are not definitive characteristics of an eating-disordered population. The fact that this is supported by the dream material in the study, is an indication of the potential of dreams to portray accurate psychological experiences. 1.6. Invasion of Privacy. Both Bruch (1978) and Minuchin (1978) speak of the high level of intrusiveness occurring in anorexic families. Root et al. (1986) have found similar patterns of intrusiveness occurring for bulimics across all three 55 identified family types. Thus significant differences in the occurrence of images suggesting invasion of privacy were expected between the two groups. However, these were not found, neither at an individual item level, nor in the combined items of the dream material. There would appear to be some interchange between the images suggesting "a sense of being watched and judged by others" and those ascribed to "invasion of privacy" (see Appendix C for Dream Scale). The insufficient clarity between the two categories could well be clouding the results. Improvements need to be made to the dream rating scale in order to clarify images suggesting a sense of invasion of privacy. 1 1.7. Sense of Being Watched and Judged by Others. This category in the dream material would appear to need more investigation. Statistical significance occurred only in the individual image "being watched as if guilty of something or inadequate". When combined with the image "being caught doing something socially unacceptable", significance was lost. As previously suggested, there would appear to be some intermingling of dream images between hypotheses 1.6 and 1.7 as they currently stand. More dreams need to be studied to improve accuracy in rating. 1.8. An Inability to Self-Nourish/Self-Nurture. The occurrence of this theme was statistically significant in the ED group's dreams. Lehman and Rodin (1989) describe self-nurturance as "...an attitude directed toward the self that is self-comforting, accepting and supportive. Central to this self-nurturance attitude is the ability to derive pleasure from positive experiences and cope effectively with 1 Rater suggestions of additional dream images to be included in the Dream Scale can be found in Appendix T 56 negative ones" (p. 117). Lehman and Rodin, who cite Murray's (1938) theory of feeding as the central construct of nurturance, found high levels of self-criticism, and low perceived self-efficacy, to be related to low ability to be self-nurturant. The significant differences found in the dream material of the ED group in (a) the ability to self-nourish, (b) the presence of self-hate, and (c) low perceived self-efficacy, are consistent with the links found between these three psychological states by Lehman and Rodin (1989). 1.9. Blocked Emotions. A significant presence of "blocked emotions", as defined by images of blocked toilets, was not found in the ED group's dreams. The presence of this psychological state in eating-disorders needs further clarification. Woodman (1982) writes of the blocked emotions of eating-disordered women, yet other researchers see only anorexics as overcontrolled, and bulimics as emotionally turbulent (Garfinkel & Garner, 1982; Garner et al., 1983; King, 1963; Solyom et al., 1983; Strober, 1980; cited in Garner et al, 1985). However, bulimic behaviour is understood by many clinicians to be linked to the suppression of negative emotions such as anger (Root et al., 1986; Dana & Lawrence, 1988). It would appear that the psychological state of blocked emotions as it is symbolized in dreams, needs more research. The symbol of blocked toilets could be only one of many symbols. The data collection period would probably need to be substantially longer than four weeks, or the subject group much larger than 23, in subsequent research, for significant incidences of particular symbols to occur. Of interest is the fact that no images of blocked toilets occurred in either group, and there were only three occurrences of toilet images in the total dream collection: two in the normal group, and one in the eating-disordered group. Research focused on the personal meaning of individual dream symbols might be a more accurate way to explore this psychological state. 1.10. Obsess ion with Food. An unanticipated finding was the lack of significance in the presence of food images between the two groups. Starvation victims are known to obsess tormentedly with ideas of food (Keys, Brozek, Henschel, Mickelsen, & Taylor, 1950, cited in Wooley & Wooley, 1985), thus a significant amount of food images were expected in the ED group. However, Jung's compensatory theory is one explanation for this finding (Jung ; 1934/1970; Samuels, 1985), because eating-disordered women act out the endless preoccupation with food in their waking lives, with the deeper psychological sense of being unable to attend to their own needs remaining below consciousness. Dippel et al.'s (1987) comparison of (a) the dreams of bulimics and anorexics, and (b) the dreams of eating-disordered and depressive patients, found 3 2 % more food images in the dreams of bulimics versus anorexics, and 4 4 % more food images in eating-disordered patients' dreams versus depressed patients. However, the researchers do not appear to have differentiated between the mention of food, and hostile acts by food or images of insufficient food. The latter were included in the current study under the category of "inability to self-nourish/self-nurture". 1.11. An Obsess ion with Weight. Garner and Garfinkel (1979) state that the E A T is particularly sensitive to behaviours associated with a driving preoccupation with thinness. Therefore, the significant occurrence of an obsession with weight in the dreams of eating-disordered women is in agreement with the high mean obtained by the subject group on the E A T (Table 4.3). Despite the category being restricted to weight and shape dream themes, rather than a more general themes of body image concerns (see Appendix T), a 58 significant difference was found between the two groups. If dreams are viewed strictly as compensatory to conscious awareness, then the result is somewhat surprising, given the acknowledgment most of the eating-disordered subjects made of their weight and body image fears. However, dreams are also understood as messages to facilitate healing (Faraday, 1972; Rossi, 1985; Sanford, 1978; Ullman & Zimmerman, 1979). Weight gain images in the eating-disordered women's dreams were all accompanied by extreme emotions such as shock, horror, panic or wanting to die, which appear to indicate the peripheral ego structure of anorexic and bulimic women. Hypothesis 2 Negative Emotions. The significant presence of negative emotions in the E D group's dreams confirms hypothesis 2. This parallels a significantly higher level of neurotic symptoms found in the ED group on the HSCL. It also demonstrates agreement with Deci and Ryan's (1985a) theory that true enjoyment is the characteristic of the autonomy orientation, with tension and anxiety as the prevalent emotions accompanying the control and impersonal orientation. Positive emotions were not rated in the dream scale, which is an area future research might address. The Ending of the Dream The significant presence of a sense of impending doom in the ending of the ED group's dreams is an important finding. Little is written of the meaning of the ending per se in dreams, barring the observation by Levitan (1981b) that women suffering from rheumatoid arthritis do not wake up at the occurrence of the threat, as is usual, but go on to experience the effects, such as the process of being eaten. Levitan understands this as the result of a high level of self-deflected hostility, which is somatized in the self-devouring disease of rheumatoid arthritis. Samuels et al. (1986) note that certain nightmares serve the purpose of disintegrating or demolishing the dream ego, as a call to alter one's life course. The sense of threat, either being maintained or increased at the end of the dream, may specifically refer back to the original threatening or traumatic event of the dreamer's life. Therefore anxiety about what has happened is displaced into what might happen (A. Samuels, personal communication, March 20, 1991). P. Biela (personal communication, March 23, 1991) states that the dream ending is an important communication of past, present and future events in the dreamer's life. The sense of threat captures the dreamer's pessimism, the overriding belief system that a threat is always around the corner. Biela understands nightmares with resolved endings as communicating the belief system that though things may be bad, the dreamer will get through them. Biela's (1991) interpretation can be linked to perceived self-efficacy levels, which is substantiated by findings in the dreams and G C O S . Samuels' (1991) view of the dream ending addresses the important aspect of psychological woundedness, discussed further under "theoretical implications". It would seem that the nature of the dream ending can convey valuable information, both of the underlying belief system, and the history, of the dreamer. Future dream research might look at the links between these aspects. General Causality Orientation Scale The G C O S , in conjunction with the Dream Scale, was used to assess the presence of a sense of ineffectiveness in the E D group. The significant differences 60 found between the two groups in both the autonomy and impersonal orientations are in contrast to Strauss and Ryan's study (1987), which found significance only in the impersonal orientation, and confined to the restrictive anorexic group. The contradictions in autonomous functioning between the projective and the self-report tests, observed by McLaughlin et al. (1985), and between the projective test and the G C O S specifically, observed by Strauss and Ryan, were therefore not found in this study. However, there was a more distinct group difference in the impersonal orientation in this study, which matched significance levels found by Strauss and Ryan in the restrictive group. Given the differences found between the two orientations in both studies, and eating-disordered women's high need to present themselves as perfect, it would appear that the intent behind the impersonal options on the G C O S may be less obvious to the respondents than those of the autonomy options. The Use of Questionnaires Versus Dreams Several researchers have raised the question of the limited value of self-report questionnaires with an eating-disordered population, who are known to manifest a high level of denial as one of their major defenses (Brouillette, 1988; McLaughlin et al, 1985). In this study, results from the G C O S supported the results from the dreams, where applicable. However, in the individual subject profiles, contradictions occurred in data of two ED subjects: subject F, who scored well below the mean of the Non-ED group on all the subscales of the HSCL, and 9 on the EAT; and subject L whose scores on the G C O S and the H S C L were close to the means of the Non-ED group. Both subjects' individual scores on the Dream Rating Scale were similar to the means of the ED group in significant areas (e.g., 61 sense of ineffectiveness; self-hate; & dream ending in a sense of impending doom). Subject F's therapist was clear that she fit the DSM-111-R diagnostic criteria for bulimia. Subject L, a restrictive anorexic who had refused any type of treatment, was declared by the referring psychologist to be dangerously compromised by her low weight and high level of denial. It would seem therefore that in eating-disorder cases where there is resistance to treatment or denial of the severity of the problem, dreams might provide a means of increasing the dreamers' awareness of her problem. Further research needs to be done in this area. Additional Themes Found in the Dreams The raters noted several themes not accounted for in the Dream Scale. These were: (a) a need to be special (ED: 7 dreams; Non-ED: 1 dream); (b) feeling isolated or left out (ED: 5 dreams; Non-ED: 0 dreams); and (c) a neurotic sense of power (ED: 3 dreams; Non-ED: 0 dreams); see Appendix T for details. Images of illness and death occurred in eight out of the total 275 dreams. Surprisingly, these images occurred in equal numbers in both groups of dreamers. However, themes of the dreamer experiencing pleasure and relief at the news of her impending death occurred only in the ED group. This theme was noted in the dreams of Ellen West, who ultimately committed suicide (Binswanger, 1958). It seems worthy of mention that these themes occurred in the dreams of subjects H and I, who scored the highest on the E A T scale, as well as in the top third of the depression subscale of the H S C L (see Appendix R for subject profiles). Theoretical Implications of the Dream Findings 62 Dream Illustrations This section presents individual dream examples, some of which are examined within a framework of psychodynamic theory. Themes of Psychological Woundedness. Solomon (1990) speaks of psychological woundedness at a pre-verbal stage in development as the root of the extreme ego-fragility in narcissistic disorders. Two dreams from the two subjects seen to be the most resistant and the most entrenched of the ED group by the researcher, portrayed graphic images of wounds (see Appendix R for subject profiles): Subject E War broke out and these Chinese or Japanese people lined us up and cut off our hands and feet so we wouldn't get away. When it came to my turn, I yelled "Dear God, help me!" and then they were cut with a paring knife. I was really upset because I kept going on that I wouldn't be able to heal. Feelings: Helplessness; acceptance of the inevitable (underline added) Subject L My sister and I are in a shopping centre in Montreal. At a make-up counter there is a woman exhibiting a product-offer. We ask her for information and she speaks unintelligibly. Suddenly a large lump forms on her throat. It seems to be breathing. Her neck splits open as she falls to the ground. A large black frog sits inside the wound. The claws are fierce. The woman is just about dead and nobody knows how to help her. The frog turns and buries itself down her throat inside her chest. Feelings: Repulsion; disgust (underline added). Of interest is the enormity of the wounds, and the ferocity with which they are inflicted. In the second dream, the tenacity of the frog's claws and its "digging in", with accompanying feelings of disgust and repulsion, rather than the more appropriate feeling of compassion, seem to symbolize both the entrenchment of subject L's psychological state, and her poor prognosis, borne out by her refusal to 63 be treated despite the seriousness of her condition. The two dreams appear to support Sabini's proposal (1981) that dreams can offer clues to prognosis. Jung's (1934/1970) theory that the dream portrays the accurate condition to the dreamer can be seen in both dreams, but most particularly in the line "The woman was almost dead and nobody knows how to help her". Future research might include dream images of wounds, and bleeding, in the category of ego fragility. Themes of Unmet Needs in Early Childhood. Spignesi (1983) writes of the inappropriate feeding of the daughter by the mother in the early childhood of eating-disordered women. This "...mother does not feed the child with food at appropriate times,...[but]... with hei needs, her desires, her unfulfilled ambitions" (Spignesi, 1983, p. 44). A particular theme occurred solely in the dreams of eating-disordered women which appears to support the idea of unmet needs in early childhood. There were five dreams, from subjects D, F, J and K, portraying images of babies receiving inappropriate care, or insufficient care through the dreamer lacking the means or knowledge to feed and appropriately nurture it. Either the dreamer was too sick to take care of the baby, had insufficient milk, or was treating the baby extremely inappropriately such as putting it to sleep in a bowl of jello in the refrigerator. In one dream, the dreamer's mother was going away, yet again, so that there would be no-one to help a woman deliver her baby. The dreamer experienced a great deal of anger in this dream, which can be understood as rage over her unmet needs in infancy (see Appendix S for dream reports). Subject M in the Non-ED group had a dream of a baby at risk, although the theme was somewhat different: 64 I am talking to someone on the phone. We are in tall cement apartment buildings with windows, no balconies. Across the building a baby climbs out of the window and is falling. The woman is screaming that her granddaughter fell out of the window. She is horrified. She is screaming for help and trying to find what can be done as the baby is falling. It seems worth noting that subject M was the most symptomatic of the Non-ED group (see Appendix R for subject profiles). Although it would appear from this dream that subject M might have been psychologically hurt in infancy, the woman in her dream is screaming for help, and trying to find out what can be done, which appears to indicate a healthy drive to heal. The theme in subject M's dream is of a baby being inadequately protected, rather than a theme of inappropriate caretaking, or insufficient nourishment, which might be the definitive difference in eating-disordered women's dreams. More dreams would have to be studied to verify this. Themes of a Neurotic Sense of Power. All three dreams judged by the raters to portray a neurotic sense of power, came from subject L This subject, discussed earlier as dangerously at risk due to her low body weight and high level of denial, demonstrates in her dreams the sense of originality, special powers and superhuman strengths that Bruch (1985) noted as her patients' way of dealing with their core feeling of ineffectiveness: 1. I am in an old house filled with people. Unbeknown to others, there is a monster-like creature roaming from room to room. The creature has been designed to kill those who are suspected of witchcraft. I am a suspect. I know my beliefs are valid and should be expressed, but somehow, someone doesn't want to hear them. 2. I am running from room to room in a very large futuristic building. The structure is built upon the sea, yet there is a sense of stability....! am being chased for I am a rebel in a strict society. I know I am right in my thoughts and actions, so I must escape (accompanied by feelings of excitement and pleasure in her uniqueness). 3. I am a blue dot. I am the leader in the blue-dot world. Our enemies are the red dots. I have great power and can perform fantastic feats. There is a battle which takes place on a beach which is cold, grey and stormy. The 65 wind and the crashing waves are intensely noisy (accompanied by feelings of power and accomplishment). There is much in these dreams indicating the vulnerability of subject L's "rebellious" position, such as the paradox of being built on the sea, yet feeling stable, and the image of the blue dot, as in deoxygenated, depleted blood, at war with the red dots, as in healthy, oxygenated blood. The symbol of the "dot" might indicate her true sense of her internal self as extremely insignificant. Two other dreams out of subject L's 12 dreams also mentioned a sense of power, accomplishment and determination in the presence of a stormy and unstable environment. Kernberg (1975, cited in Davis & Marsh, 1986) found a sense of omnipotence to be a defence against chronic intense envy in narcissistic personality disorders. It would appear that a neurotic sense of power and the need to be special are interwoven, stemming from the need to fill a painful sense of deficiency. They do, however, appear to manifest in distinctive dream images (see Appendix T). Themes of Unaroundedness. Subject F had a dream which seems to illustrate Woodman's (1982) theory of a sense of ungroundedness symbolizing disconnectedness with the archetype of the good mother: Two young boys are playing near a rocky hill. The younger boy goes into a cave and brings out a rock about the size of a baseball. They take it home and give it to their mother, who crushes it and produces a bowl full of pink crystals, which she states are rubies. The mother goes into the cave and brings out two large crystals. Then she goes in again - this time there is an explosion or earthquake, and the cave opening collapses. The boys are outside, waiting to see if their mother will reappear. The mother is portrayed here as someone who can offer treasures, yet her "treasured" aspects have been lost, probably at the age of the young boys in the dream. Images of Resistance to Therapy. Subject L had a dream which appears to demonstrate Sabini's (1981) theory of the dream's potential to reveal resistance to therapy: We are installing a new alarm system in our house to prevent intruders from getting access. It is a very complex system involving computers, lasers, sound etc (accompanied by a feeling of severe disappointment in society). Subject L had refused treatment, and her dream paints a graphic picture of the blocks met by the health professionals in their attempts to "get through" to her, revealing at the same time her sense of moral superiority in her anorexic stance. Dreams as a Metaphor of the Specific Illness. Subject D had a dream which could be understood as symbolizing the process of her illness. I was riding a horse that had been wild at one time. I managed to tame it and ride it. As I sat on the horse's back, I felt the strength disappear from my horse. Soon the horse was very sick and I ended up carrying it. Then I was in a stable, meeting with some people. I remember trying to get them to make my horse better (accompanied by feelings of sadness and loss). There is little in this dream that could be analyzed by the Dream Rating Scale as it currently stands, other than the attitude "I can only succeed if somebody helps me". However, much can be seen in this dream if it is viewed as a narrative of how Subject D's eating-disorder developed. If one takes the approach of the horse representing her wild and instinctual spirit, then this dream supports etiological theories that the eating-disordered woman curtails individuality and independence for the sake of acceptance. The ultimate price of the suppression of self is illness. Limitations of the Study Although the Dream Rating Scale was given a preliminary testing before using it in the study, it has not been subjected to the rigorous testing required to produce a 67 standardized rating scale. Although inter-rater reliability was high, more work needs to be done to the dream scale, such as factor analysis of the 90 items. The generalizability of the scale to other eating-disordered samples has not been tested. Therefore, the results of the study are to be viewed with caution, bearing in mind the exploratory nature of the research. The data gathered from the current study may provide material for a dream scale of a more comprehensive nature in the future. Secondly, although a fairly large number of dreams were generated in the study (275), the source of the dreams was relatively small (n = 23). In addition, the subjects for the study were not randomly selected from the volunteers. The fact that the dreams may not have come from a representative sample needs to be remembered when interpreting the results. Further research with a larger sample needs to be done to validate these findings. Suggestions for Further Research The dreams in the study have been shown to demonstrate a significant sense of low perceived self-efficacy in the eating-disordered subjects. This psychological trait has been receiving particular attention in recent years as the major block to recovery in anorexic and bulimic women (McLaughlin et al., 1985; O'Leary, 1985; Schneider et al., 1987; Strauss & Ryan, 1987; Wagner et al., 1987). Research to date has examined the effect of cognitive-behavioral methods on perceived self-efficacy levels (Schneider at al., 1987). Future research might look at the effectiveness of dream therapy on perceived self-efficacy ratings. 68 There are several research questions arising out of the current study. Are there differences between the dreams of anorexic women and bulimic women? Would a study of the recurring dreams of eating-disordered versus normal women reveal different results? Would a study of the dreams of women with chronic eating-disorders reveal a higher incidence of images of ineffectiveness than in the dreams of women with acute eating disorders? Do anorexic and bulimic men have similar dreams to eating-disordered women? It can be seen how the 11 psychological themes isolated in the hypotheses connect and inter-relate, such as an obsession with weight being rooted in ego-fragility, the interconnectedness of low self-nurturance, high self-criticism and low perceived self-efficacy, and the theme of narcissistic woundedness pervading all of the psychological states. In the same way, connections and overlaps can be expected in the dream images. Content analysis is one way to access the meaning of dream material. Phenomenological research, which focuses on the individual dreamer's experience of the dream, could add a valuable dimension to the results of this study. As can be seen in the examination of the dreams of subject L, a case study approach provides evidence of themes, which was lacking in the method used in this study. Future research might give whole dream series to individual raters as a way of accessing significant themes in eating-disordered women's dreams. 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New York: Guildford Press. 79 Appendix A Formulation of dream rating scale The dream rating scale was formulated by the researcher, in consultation with Dr. John Allan (personal communication, August,1987 to March, 1988). Data from an unpublished pilot study (Brink et al., 1987) and dream reports from the literature (Binswanger, 1958; Levitan, 1981a; Selvini-Palazzoli,1963/1973; Sours, 1980; Thoma, 1967; Weizsacker, 1937; Woodman, 1982, 1985a) were examined and nine themes were isolated. These were: 1. Helplessness. 2. Entrapment and being stifled. 3. Food. 4. Self-mutilation 5. Fragmentation 6. Violence 7. Body-image concerns 8. Sense of being watched and judged 9. Invasion of privacy. The themes of helplessness seemed to be conveyed by attitudes, behaviours, emotions, and images in the dreams, which were understood to be indicating a sense of ineffectiveness (see Appendix B & C for classification of items). The following are some examples of attitudes of ineffectiveness found in the dreams used as baseline data. 1. K is cutting her arms and I walk into the room and find her. When this happens, I get angry and tell her not to hurt herself because I care about her. In response, she goes into the bathroom and procedes (sic) to cut her arms and legs more. I feel helpless and sad (Brink et al., 1987). 2. I have cotton wool, which turns out to be fibreglass with razor sharp particles in it, stuck in my mouth and down my throat. I slowly and painstakingly try peeling it away with my tongue or whatever my fingers can reach. I feel panicky that I may not be able to remove it all. I panic that I may choke or suffocate on my own mucous (Brink et al., 1987). 3. I am standing in front of my mother. I would like to do something, but my feet are two bleeding stumps (Selvini-Palazzoli, 1963/9874, p.87). 4.1 am back in my old school neighbourhood. A siren goes off warning all that a bomb is set off to explode and kill everyone in five more minutes. I run to the school and hide in a washroom in the basement under the sink. I am literally terrified, and there's no-one else around. I can feel the minutes ticking away and I'm waiting what seems like an eternity to die. The dream never seems to end. I just wait, terrified, with the time ticking away (Brink et al., 1987). 80 The themes of entrapment and being stifled were found in images and emotions, and were understood to represent the experienced of being rigidly controlled. An example of a dream portraying both entrapment and stifling images: 5. I am in the lake at our country place. I'm underwater; its murky and warm. I am wearing a mask. It takes my full concentration to breathe in and out rhythmically, or else I don't get any air and I suffocate. I'm feeling panicky. Somehow, my sister is with me. She insists that I apologize to those that I have wronged, and I insist on telling the truth (Brink et al., 1987). Food images took two forms: (a) straightforward images of food, places of eating, people connected with eating, utensils connected with eating; and (b) images of food as hostile or threatening; rotten, spilled or in some other way inedible; or simply being unavailable or insufficient. Food images in category (a) were taken as indicating an obsession with food, while those in category (b) were understood to indicate an inability to self-nourish, which is a surface manifestation of the underlying difficulty with self-nurturance (Lehman & Rodin, 1989). The following are some dream examples of food-related images falling into category (b): 6.1 am washing the dishes at the restaurant and there is an enormous pile of dishes, they pile up and up and then fall in on me and start to eat me. I can't breathe (Brink et al., 1987). 7. I am being overpowered by a huge navel orange. It is about to devour me...I am suffocating...In a funny way it is as though it is overtaking the world (Levitan, 1981a, p. 229). Dream number 2 was also an example of the inability to self nourish, namely in the that the alimentary tract has foreign, non-nourishing matter in it; in this case, not only foreign, but also harmful matter. Images of the dreamer or dream figure harming herself in some way were understood as indications of self-hate. An example of a self-mutilation image can be seen in dream number 1. Suicidal dreams such as the dreams of Ellen West quoted in Chapter 2 (Binswanger, 1958) are a further example. The dreams collected in the pilot study (Brink et al., 1987) showed several images of shattering glass and imminent bomb explosions, which, together with Woodman's (1982) reports of images of collapsing or disintegrating foundations, were understood as symbolizing ego-fragmentation. The following dream, together with dream number 1, are examples: 8. In the cafeteria there are many people sitting around the table during dinner. M. walks into the room and drops a glass on to the floor, sending shards in all directions. Upon picking up a piece of glass, she begins to cut her arms to a bleeding mess. I scream for somebody to stop her, but she just walks away with another piece her hand and nobody runs to help. 81 Dreams of violence, understood as an expression of the dreamer's anger, appeared in the form of scenes of violent catastrophe, or images of the dreamer attacking dream figures, such as in the following examples: 9. I am coming out of the school one day and there are people dead all over the school -1 don't know who they are - a couple are alive and I see them getting shot - all of a sudden their insides just get blown inside out (Brink et al., 1987) 10. A woman who looked like my mother was trying to get into my house...I started to hit her head with a hammer...I kept it up until her head was soft and blue like jelly (Levitan, 1981a, p. 230). Dreams of violence towards the dreamer were understood as expressions of self-hate. Invasion of privacy images, and images suggesting body-image concerns can be found in Appendices B and C. Dream understood to contain themes of a sense of being watched and judged were found both in the literature and in the baseline data (Brink et al., 1987); see appendices B and C. Many of the dreams were noted to end with a sense of threat or impending doom. An item rating the ending of the dream was therefore included in the scale. Two additional images were noted, namely: (a) images of huge or monstrous dream figures, usually in connection with food or eating, and (b) images of blood, from some type of wound. These were included in the dream scale without being connected to any particular psychological state. All the emotions stated in the surveyed dreams were listed and included on the scale. Forty-one "negative" emotions were isolated. A few "positive" emotions were isolated, but only one was clearly positive: 11. ...Then I had a tremendous urge to eat...I ate six hot dogs in a row...I kept stuffing them in...I could taste them in my sleep...delicious...I began to feel good (Levitan, 1981a, p. 230). The remaining positive emotions were connected to negative events, such as the experience of relief or exultation at the approach of death. These were not included in the scale. The scale was tested on a student rater three consecutive times to check for ease of rating and comprehensibility of the items. Adjustments to the scale were made accordingly. For suggested changes and additions to the scale subsequent to the current study, see Appendix T. Appendix B Hypothesis categories 1.1 .Low perceived self-efficacy 1. Whatever I do I won't succeed. 2. I may succeed, but change seems so slow I feel anxious and discouraged. 3. I can only succeed if somebody helps me 4. Struggling and/or screaming with no change being effected. 7. Endless waiting. 27. Helplessness/powerlessness 28. Hopeless 39. Overwhelmed 40. Out of control 83. Being chased with no obvious escape. 86. Dreamer in a frightening situation of an impersonal nature. 88. Injured arms or legs. 1.2.Presence of anger 8. Anger 23. Frustration 26. Hate 30. Hostility 32. Impatient 33. Irritated 70. Dreamer attacking person, animal or thing. 71. Dream figure/s victim of violent action 72. Scenes of violent catastrophe I. 3.Self-dislike (anger turned inward) II. Feeling bad 17. Feeling disliked. 18. Embarrassment/humiliation/shame. 25. Guilt 44. Suicidal/wanting to die 48. Feeling unloved 65. Dreamer/dream figure deliberately cutting or injuring self. 66. Dreamer attempting or committing suicide. 84. Dreamer being attacked by person, animal or thing. 1.4. Fragmented eao 67. Glass breaking. 68. Bombs exploding. 69. Disintegrating foundations, collapsing parking lots, tunnels etc. 1.5. A sense of being rigidly controlled 46. Trapped 50. Imprisonment/captivity of dreamer 51. Dreamer having difficulty breathing. 83 52. Dreamer/dream figure suffocating. 53. Dreamer/dream figure trapped by something impersonal. 54. Dreamer being held against will and not let go. 55. Dreamer being forced to do something against her will. 1.6.lnvasion of privacy 80. Dreamer/dream figure feeling spied on. 81. Eyes watching dreamer. 82. Someone going through dreamer's/dream figure's private things. 1.7. A Sense of Being Watched and Judged by Others 78. Sense of being watched as if guilty of something, or of being inadequate. 79. Being cauoht doing something socially unacceptable, eg. stealing, bingeing etc. 1.8. Inability to self-nourish/self-nurture 5. Vomiting. 6. Taking laxatives. 19. Feeling empty. 56. Aggressive acts by food. 62. Non-food in the digestive tract. 63. Food in hostile or inaccessible places. 64. Dreamer/dream figure unable to get enough food. 1.9. Blocked emotions 90. Toilet images (plugged/overflowing/inaccessible toilets). 1.10.Obsession with food 57. Food. 58. Food-related incident. 59. Food-related objects. 60. Food-related places. 61. Food-related people. 1.11 .Obsession with weight 73. Very fat people. 74. Very thin people. 75. Dreamer/dream figure having a neg. reaction to weight gain. 76. Dreamer having a positive reaction to weight loss. 77. A sense of weightlessness. 85. Ethereal beings (wraiths/ghosts/spirits/angels). Appendix C Dream Rating Scale * Refer to Explanation Sheet ATTITUDES * 1. Whatever I do I won't succeed *2. I may succeed,but change is seems so slow I feel anxious and discouraged *3. I can only succeed if somebody helps me BEHAVIOURS 4. Struggling/screaming with no change being effected *5. Vomiting *6. Taking laxatives 7. Endless waiting EMOTIONS 8. Anger 9. Anxious/tense 10. Abandoned 11. Bad 12. Betrayed 13. Confused 14. Desperation 15. Disappointed 16. Disgusted/repulsed 17. Disliked 18. Embarrassment/humiliation/shame 19. Empty 20. Exposed/vulnerable 21. Fear/frightened/scared/fearful * Refer to Explanation Sheet 22. Frantic 23. Frustration 24. Grief 25. Guilt 26. Hate 27. Helplessness/powerlessness 28. Hopeless 29. Horrified 30. Hostility 31. Hurt 32. Impatient 33. Irritated 34. Isolated/separated 35. Jealousy 36. Lonely/alone 37. Lost 38. Misunderstood 39. Overwhelmed 40. Out of control 41. Panic 42. Sadness 43. Shock 44. Suicidal/wanting to die * Refer to Explanation Sheet 45. Terror 46. Trapped 47. Upset/unhappy 48. Unloved 49. Worry IMAGES Entrapment Images *50. Imprisonment/captivity of dreamer 51. Dreamer/dream figure having difficulty breathing 52. Dreamer/dream figure suffocating *53. Dreamer/dream figure trapped *54. Dreamer held against will and not let go *55. Dreamer/dream figure being forced to do something against will Food Images * 56. Aggressive acts by food *57: Food *58. Food-related incident *59. Food-related objects *60. Food-related places *61. Food-related people *62. Non-food in digestive tract *63. Food in hostile or inaccessible places * Refer to Explanation Sheet *64. Dreamer/dream figure unable to get enough food Self-Mutilation Images 65. Dreamer/dream figure cutting or deliberately injuring self 66. Attempting/committing suicide Shattering Images 67. Glass breaking 68. Bombs exploding or about to explode 69. Disintegrating foundations, collapsing parking lots, tunnels, etc. Violence *70. Dreamer attacking person, animal, or thing * 71. Dream f igure/s victim of violence 72. Scenes of violent catastrophe Bodv-lmage Concerns 73. Images of very fat people 74. Images of very thin people 75. Dreamer/dream figure having a negative reaction to weight gain 76. Dreamer/dream figure having a positive reaction to weight loss 77. Sense of weightlessness Images of Interpersonal Sensitivity 78. Sense of being watched as if guilty of something, or of being inadequate 89 * Refer to Explanation Sheet 79. Being caught doing something socially unacceptable, e.g. stealing, bingeing etc. Images of Invasion of Privacy 80. Dreamer/dream figure feeling spied on, or continually watched 81. Eyes watching dreamer 82. Someone going through dreamer/ dream figure's private things Miscellaneous Images 83. Being chased with no escape *84. Dreamer being attacked by person, animal or thing *85. Ethereal beings *86. Dreamer in frightening situation over which she has no apparent control *87. Huge or monstrous dream figures *88. Injured arms and/or legs *89. Dreamer/dream figures bleeding *90. Toilet images EP ' 91. End State of the dream: Please mark one category Resolution Left Open-ended Sense of Impending Doom 90 Explanations N.B. Dream figures refers to people and/or animals in the dream other than the dreamer. 1. Whatever I do I won't succeed: Dreamer attempts to change distressing situation but is unable to. 2. I may succeed, but change seems so slow I feel anxious and frightened: Dreamer attempts to change distressing situation, with a sense of being able to succeed eventually, but progress is so arduous she remains anxious. 3. I can only succeed if someone helps me. 5. Vomiting. Dreamer does not attempt to change distressing situation, waiting to be saved. Dreamer/dream figure: wanting to vomit but being unable; actual vomiting. Feeling nauseous, or vomiting from  shock and/or disgust do not rate as  vomiting in this study. 6. Taking laxatives 8 - 49. Emotions. 50. Imprisonment of dreamer. 53. Dreamer/dream figures trapped. 54. Dreamer being held against will and not let go. Dreamer/dream figure: Thinking about laxatives and/or buying laxatives and/or taking laxatives. Stated in the dream, or at the end under"Feelings". If an emotion is stated once in the dream it is 'P'. If more than once in the dream, it is 'EP'. If the emotion is preceded by 'very', 'extremely' etc, or is underlined, or written in capitals, it is 'EP'. Being imprisoned by someone or a. group of people. Trapped by something impersonal such as a wall, a flood, being underwater etc. There must be the presence of being forcibly held bv someone. 91 55. Dreamer/dream figure forced to do something against her will. 56. Aggressive acts by food/food-related objects. Being made to do something that does not involve being held by force. Being attacked by food, dishes, utensils etc. Attacked but not really hurt = P; Really hurt, or overwhelmed, suffocated etc = EP. 57. Food. 58. Food-related incident. 59. Food-related objects. 60. Food-related places. 61. Food-related people. 62. Non-food in digestive tract. 63. Food in hostile/inaccessible places. 64. Dreamer/dream figure unable to get enough food. 70. Dreamer attacking person.animal or thing. 71. Dream figure/s victim of violent action. 84. Dreamer being attacked by person, animal, or thing. 85. Ethereal beings. Anything considered edible and nourishing for humans, not including  alcohol, tea, or coffee. Going out for a meal, preparing a meal, having company round to a meal. Dishes, utensils, plates etc. Dining rooms, kitchens, cafeterias, restaurants etc. Dieticians, chefs, waitresses, restaurateurs etc. Non-nourishing matter eg. excreta; foreign matter eg. cotton wool, hair; invasive matter eg. sharp objects. Food locked/stored in unusual/ difficult to access storage places = P; food guarded by weapons or hostile guards = EP. Wanting more food but being unable to get any; having food withheld; running out of food. If this is one meal = P; if in a state of continuous deprivation with threat of starvation = EP. Attacked but not injured = P; attacked and injured = EP. Being shot, mutilated etc but not by  dreamer. Mildly hurt = E; Badly hurt/dead = EP. No bodily harm = P; Bodily harm e.g choking, injury, rape = EP. Wraiths, ghosts, spirits, angels. 92 86. Dreamer in a frightening situation over which she has no apparent control 87. Huge and/or monstrous dream figures. 88. Injured arms and legs. 89. Dreamer/dream figures bleeding. 90. Toilets. Threat or presence of a disaster of an  impersonal nature which she would have no way of overcoming eg. natural disaster, war, collective hostility. Ominous sense of/ threat = P; Presence = EP. People, animals, or things much bigger than in reality, or grotesque and frightening. Huge but not harming = P; Being harmful = EP. Cuts, lacerations etc that do not seriously affect mobility = P; truncation or mutilation so that mobility is impossible or seriously affected = EP. Bleeding but not very hurt = P; Bleeding and seriously hurt = EP. Toilets; plugged toilets; overflowing toilets; inaccessible toilets. 91 .Ending of the dream: Dream has a clear sense of ending; of a) Resolution completion. If a sense of threat or danger has been present in the dream, this is resolved in some way in the final sentence, accompanied by a reduction in tension. b) Left open-ended Dream meanders to an end. No sense of closure, either negative or positive. c) Sense of impending doom Dream end with a sense of threat or worse; negative, problematic issues coming up in the last sentence. Either the introduction of a sense of threat in the last sentence, or a maintenance of the sense of threat that was present before the final sentence. 93 Appendix D Recruitment letter to therapists Dear D r . — , I am a graduate student in counselling psychology at UBC , currently working on a thesis for my Master's degree. I am hoping to receive your assistance in finding subjects for my research. My area of study is eating disorders. I am looking for female subjects between the ages of 15 - 35 years, suffering from either anorexia nervosa or bulimia, or a combination of the two. The study is a comparative survey of the dreams of eating-disordered women versus a control group. Baseline data indicates that I might expect to find certain themes in the dreams of women with eating disorders which are indicative of the underlying psychological processes. I hypothesize that I will find a significantly higher incidence of these themes in the dreams of eating-disordered women, than in the dreams of the controls. This study is to serve as data for further research in the use of dreams as a therapeutic tool in working with eating-disorders. Subjects need to be able to recall at least one dream per week. They will be informed that this is a study of the dreams of women from different backgrounds. Time commitment is an initial interview of 20 minutes; a 4 week data collection period during which time they will be expected to record any recalled dreams upon wakening; and a follow-up interview of approximately 90 minutes, during which they will be requested to answer three short questionnaires. I will then debrief the experience of participating in the study, and work with any dreams that are of particular concern or interest to them. I do not anticipate that recording dreams will result in any adverse reactions in the subjects. However, if clients experience a particularly distressing dream, it would be entirely appropriate that they work through the dream experience with their attending therapist. Subjects' names and dream material are strictly confidential, and dreams and questionnaires will be number-coded for anonymous analysis. If you have any clients who might be suitable for this study, I would appreciate your giving them the information on the accompanying sheet. Those who are interested in participating are requested to inform you, so that you can call me with the relevant information. I can be contacted at . I am available to answer any questions or concerns that you might have. My supervisor, Dr. , can be contacted at . Yours sincerely, 94 Appendix E Volunteer Information Do you remember your dreams? Would you like to know what they mean? if you are female, between the ages of 15 - 35 years, and you remember at least one dream a week, read on: My name is , and I am a U B C graduate student in Counselling Psychology. I am studying the dreams of women from different backgrounds as part of my Master's thesis. I am looking for volunteers who would be willing to write down their dreams for a period of four weeks. This should involve no more than 10-15 minutes upon waking, two or three times a week. At the end of the four weeks, I will meet with you and spend some time helping you to make meaning out of a dream or dreams which have been of particular interest to you. I am experienced in working with dreams, and this is my way of saying "thank you" for participating in the study. At this time I will be asking you to fill in 3 questionnaires which should take about 30 minutes of your time. I will also issue you with a list of books about dreams, if you have any wish to do further reading on the subject. This study is completely confidential, and all volunteers' dreams will be number-coded for anonymity. You are also free to withdraw form the study at any point. 95 Appendix F Volunteer Advertisement , A University of British Columbia graduate student in Counselling Psychology, is studying the dreams of women from different background as part of her Master's degree. "I am looking for female cashiers or supervisors, secretaries, RN's, LPN's, and restaurant workers, between the ages of 20 and 35 years, who are able to recall at least one dream per week on average", says — , who has been involved in this research for the past year. — has found dreams to be a subject which arouses interest and curiosity, and those women who have already participated in her study have generally found it to be an illuminating. Volunteers will be required to record all their dreams for a four week period, after which they will meet individually with to fill in three questionnaires, and to discuss any dream that has been of particular interest or concern to them. "This is the reward for being part of the study," says — . "I will demonstrate how to gain personal understanding from one's dreams, and will also issue each volunteer with a booklist of further reading on the subject." Anyone who fits the above requirements, and is interested in participating in the study, is encouraged to call — at - . She assures that confidentiality will be strictly observed, and all dream material will be number coded for anonymity. 96 Appendix G Letter to Volunteers Dear — Thank-you for volunteering for the study of the dreams of women from different backgrounds. My name is and I'm a student in the master's program in Counselling Psychology at UBC. Enclosed you will find some sheets of paper on which to practice recording your dreams. The instructions as to how and what to record are on the sheets. When you come to the interview we have scheduled, please bring the dream logs with you. As a reminder, total time commitment to this study will involve: (a) a 20 minute interview prior to commencing the study, (b) 15 - 20 minute commitment each morning for 4 weeks recording any dream or dreams (bearing in mind that for many people this may mean only a couple of days a week), and (c) 90 minutes at the end of the dream collection period, 30 minutes of which will involve filling in 3 questionnaires. You may withdraw from the study at any point, and your participation or non-participation will not affect your access to services or programs in any way. I look forward to meeting you on at — . Yours sincerely, Append ix H 97 Dream log #: DATE: Write the story of the dream, even if it is only one sentence. Write it in the present tense and in the first person. At the end, record the predominant feelings you had during the dream, - not your feelings about the dream upon waking. Feeling/s: Appendix I Pre-data collection interview 1. Check that subject is familiar with the information given out about the study. Ask whether she has any questions or concerns. 2. Sign consent and give copy of consent with receipt form to subject. Remind her that she is free to withdraw from the study at any point. 3. Inform subject that since you are studying the dreams of women from different backgrounds you need some background information re: a) age; b) educational status; c) employment status; d) area of residence. 4. Ask subject about general health: a) any current problem with physical health? b) is she receiving medical treatment for any type of psychiatric illness? c) is she currently in any type of therapy? d) does she have an eating-disorder, or has she suffered from one in the past? If so, how long ago? 5. How often does she remember her dreams? 6. Instruct subject on how to complete the dream logs. 7. Inform subject that she will be called weekly during the data collection period to answer any questions or concerns. These will be brief calls, and it will not be appropriate to talk about her dreams at this point. 7. Remind subject of the three questionnaires to be answered at the end, and of the post-data collection interview. 8. Thank subject for volunteering to participate in the study. 99 Appendix J Consent Form A Study of the dreams of women from different backgrounds Investigators: Student: Supervisor: Dr. , Department of ---The purpose of this study is to collect information about the dreams of women from different backgrounds. This information will be used for further research in the use of dreams as therapy. You will be asked to answer some questions prior to commencing the study. Dream collection will take place over a specified four week period. You will be given forms on which to write your dreams, and are requested to record every dream you recall during that period, first thing upon wakening. This should take no more than 10-20 mins. Upon completion of the dream collection period, you will meet with to discuss participation in the study, and work with any dream(s) of particular interest or concern. You will also be asked to fill in three short questionnaires. Names, questionnaire information, and dream material are strictly confidential, and all information will be number-coded for anonymity. Maximum amount of time commitment to the study, presuming that you have a dream to record each morning = 11 hours. At the end of the study, you will receive a reading list to assist you with working on your dreams in the future. If you have any inquiries or concerns, please call — at . It is your right to refuse to participate, or to withdraw from the study at any time. Withdrawal from the study will not be held against you in any respect whatsoever. I have read the above information, and agree to participate in the study of the dreams of women from different backgrounds. Signature of subject: Date: Signature of investigator: 100 Receipt of copy of consent form I have received a copy of the consent form I signed to participate in the study of the dreams of women from different backgrounds. Date: Signature of subject: Appendix K Standardised Weekly Telephone Conversation 101 Hello, this is . I'm calling to find out how the dream recording is going. Have you been able to recall any dreams this week? Do you have any questions or concerns about the study or how you should be recording the dreams? Thank-you. Keep up the good work. 102 Appendix L Introductory paragraph to questionnaires A Study of the dreams of women from different backgrounds: Investigators: (student). Tel: Dr. (supervisor). Tel: The purpose of this study is to collect information about the dreams of women from different backgrounds. This information will be used for further research in the use of dreams in therapy. By participating in the study, you will learn how to record your dreams in an organized and consistent way, and you will be given information at the end which will assist you in working with your dreams in the future. You are requested to complete three short pencil and paper tests after completion of the dream collection. Dream collection will take place over a specified four week period. You will be given forms on which to write your dreams, and are requested to record every dream you recall during that period, first thing upon wakening. Upon completion of the dream collection period, you will meet with to discuss participation in the study, and work with any dream(s) of particular interest or concern. Names, questionnaire information, and dream material are strictly confidential, and all information will be number-coded for anonymity. Maximum amount of time commitment to the study, presuming that you have a dream to record each morning = 11 hours. It is your right to refuse to participate, or to withdraw from the study at any time. This will not be held against you in any way whatsoever. If this questionnaire is completed, it is assumed that consent has been given by the subject. 103 Appendix M Instructions to Raters Please read through each dream and check off whether the 90 items listed below are either absent, present, or extremely present. Please refer to the explanations assist you in making the judgements (items clarified in explanation sheet marked with *). Underline feelings in the dream as you read through. Although feelings were asked for at the end of the dream, not all subjects recorded feelings. See what you can find within the dream, but do not read possible feelings into the dream. Judge solely according to what is written. Read through the dream, then read through the rating sheet step by step and mark whether the image, behaviour etc is A, P, or EP (A = absent; P = present; EP = extremely present). These evaluations are both qualitative and quantitative. Quantitative: if an image, behaviour, attitude or emotion comes up once, mark it 'P'. If it comes up more than once, mark it EP. Qualitative: images and emotions will be P or EP according to the intensity portrayed i.e. emotions intensified by "very", "extremely" etc, or underlined, or written in capitals will be EP. Images which will be P or EP according to degree are clarified in "Explanations": #'s 56; 63; 64; 70; 71; 84; 86; 87; 88; 89. Look at the emotion accompanying any image or behaviour that is listed. If the emotion is positive, i.e. excitement in a situation such as being trapped, it would not be considered P in this study. All emotions associated with the listed behaviours  and images must be negative, or not stated, in order for the item to be considered  present. This can be understood by studying the handout on the psychological processes of eating disorders (p 10) Note the difference between #'s 78 and 80; 70 and 71; 54 and 55. Drinks, being in a bar, getting drunk are not considered food-related activities in this study. In the images, sometimes "dreamer" is written, sometimes "dreamer/dream figure", sometimes just "dream figure". These distinctions are important - please check each item to be sure you are looking at the correct participant in the dream. Sometimes an dream scenario will qualify to be scored in two or more categories. That is fine, as long as you have double-checked that each category is indeed valid for the particular scenario. IT IS IMPORTANT T O B E AS F R E E AS POSS IBLE F R O M ESTABL ISHED D R E A M  T H E O R Y IN MAKING T H E S E RATINGS, eg., in * and * * , you are asked to add your opinion as a result of information given about the psychological theories of 104 eating disorders, not according to any theories of universal meanings of symbols, or possible archetypal interpretations of the dreams. *lf there are any images, behaviours, or attitudes in the dreams, which have not been listed in the rating scale, and seem to fit one of the themes listed under "psychological themes of eating disorders under examination in this study", please add them at the end of the scale. Put in brackets the psychological state you think they represent, and mark them either P or EP. **lf there are any images, emotions, attitudes or behaviours in the dreams, which are not accounted for in the rating scale, and do not fit any of the psychological states under examination in this study, but which you consider to fit one of the themes of eating disorders not to accounted for in this study, or you consider to be significant, please add them to the list. Label the theme, and mark it either P or EP. Psychological themes of eating disorders under examination in this study 1. Low perceived self-efficacy (perceived inability to impact the environment in a positive and productive way) 2. Presence of anger. 3. Self hate/dislike. 4. A fragmented sense of self. 5. A sense of being rigidly controlled. 6. A sense of invasion of privacy. 7. Interpersonal sensitivity. 8. Inability to nourish the self/ difficulty being nurtured or nurturing others. 9. Blocked emotions/difficulty expressing feelings. 10. An obsession with food. 11. An obsession with body image. Possible psychological themes in eating disorders not accounted for in this study. (a) a pronounced need to please. (b) a need to be special. (c) experience of self as a 'thing' rather than a person. (d) fear of rejection. (e) a neurotic sense of power 105 Examples of Dreams from the Literature Father is holding me down...we are having actual intercourse...! am blindfolded but the blindfold slips...it really is him...l am struggling and screaming. I am standing and around me are heaped provisions and food which I must eat. I am very unhappy about it because all around me there are eyes, nothing but eyes, eves watching how I will eat. A pair of eyes changes into the face of my brother, how he snickers, mean and ornery. I am being overpowered by a huge navel orange. It is about to devour me. I am suffocating. In a funny way it is as though it is overtaking the world. My mother was sitting with Signora F on the drawing room sofa. I came in to say hello. As I passed Signora F I spilled blood over her lovely white dress. I was horrified and apologized profusely, then I noticed that blood was pouring from the two truncated stumps that were my arms. But while I felt guilty about the dress, I was not at all surprised about my own condition. I entered a large poulterer's shop. This shop was very cold - the whole place was one huge refrigerator. People kept stealing chickens, and to stop them the shopkeeper had put all the chickens into display cases. Next to each case two penguins stood watch. They were hideous, frightening and enormous and had sharp beaks. Append ix N General Causality Orientation Scale (GCOS) (Deci & Ryan, 1985b) 107 Individual Styles Questionnaire On the following pages you will find a series of vignettes. Each one describes an incident and lists three ways of responding to i t . Please read each vignette and then consider the responses in turn. Think of each response option in terms of how likely i t is that you would respond in that way. We a l l respond in a variety of ways to situations, and probably each response is at least slightly likely for you. If it is very unlikely that you would respond the way described in a given response, you would circle numbers 1 or 2. If i t is moderately likely, you would respond in the mid range of numbers; and i f i t is very likely that you would respond as described, you would circle the 6 or 7. You should circle one number for each of the three responses on each vignette. Below is a sample item. The actual items begin on the next page. Sample You are discussing politics with a friend and find yourself in sharp disagreement. It is likely that you would: Press forward with your viewpoint and try to get him/her to understand i t . 1 . . . . 2 . . . . . 3 . . . . 4 . . . . 5 . . . . 6 . . . . 7 very unlikely moderately likely very likely Change the topic since you would feel unable to make your point understood. 1 . . . . 2 . . . . 3 . . . . 4 . . . . 5 . . . . 6 . . . . 7 very unlikely moderately likely very likely Try to understand your friend's position to figure out why you disagree. 1 . . . . 2 very unlikely 3 . . . . 4 . . . . 5 moderately likely 6 . . . . 7 very likely 1. You have been offered a new p o s i t i o n in a company where you have worke for some time. The f i r s c question that i s l i k e l y to come to mind i s : What I f I can ' t l i v e up to the new r e s p o n s i b i l i t y ? 1 . . . ' . 2 . . . . 3 . . . . 4 . . . . 5 . . . . 6 . . . . 7 very u n l i k e l y moderately l i k e l y very l i k e l y W i l l I make more at th i s pos i t ion? 1 . . . . 2 . . . . 3 . . . . A . . . . 5 . . . . 6 . . . . 7 very u n l i k e l y moderately l i k e l y very l i k e l y - I wonder i f the new work w i l l be in teres t ing? 1 . . . . 2 . . . . 3 . . . . 4 . . . . 5 . . . . 6 . . . . 7 very u n l i k e l y moderately l i k e l y very l i k e l y 109 2. You have a school age daughter. On parents' night the teacher tells you that your daughter is doing poorly and doesn't seem involved in the work. You are likely to: Talk i t over with your daughter to understand further what the problem is. 1 . . . . 2 . . . . 3 . . . . A . . . . 5 . . . . 6 . . . . 7 very unlikely moderately likely very likely Scold her and hope she does better. 1 . . . . 2 . . . . 3 . . . . A . . . . 5 . . . . 6 . . . . 7 very unlikely moderately likely very likely Make sure she does the assignments, because she should be working harder. 1 . . . . 2 . . . . 3 . . . . A . . . . 5 . . . - . 6 . . . . 7 very unlikely moderately likely very likely 110 3. Y o u h a d a j o b i n t e r v i e w s e v e r a l w e e k s a g o . I n t h e m a i l y o u r e c e i v e d a f o r m l e t t e r w h i c h s t a t e s t h a t t h e p o s i t i o n h a s b e e n f i l l e d . I t ' s l i k e l y t h a t y o u m i g h t t h i n k : I t ' s n o t w h a t y o u k n o w , b u t w h o y o u k n o w . 1 . . . . 2 . . . . 3 . . . . A . . . . 5 . . . . 6 . . . . 7 v e r y u n l i k e l y m o d e r a t e l y l i k e l y v e r y l i k e l y I ' m p r o b a b l y n o t g o o d e n o u g h f o r t h e j o b . 1 . . . . 2 . . . . 3 . . . . 4 . . . . 5 . . . . 6 . . . . 7 v e r y u n l i k e l y m o d e r a t e l y l i k e l y v e r y l i k e l y S o m e h o w t h e y d i d n ' t s e e my q u a l i f i c a t i o n s a s m a t c h i n g t h e i r n e e d s . 1 . . . . 2 . . . . 3 . . . . 4 . . . . 5 . . . . 6 . . . . 7 v e r y u n l i k e l y m o d e r a t e l y l i k e l y " v e r y l i k e l y 111 4. You are a plant supervisor and have been charged with the task, of a l l o t t i n g coffee breaks to three workers who can not a l l break at once. You would l i k e l y handle th i s by: T e l l i n g the three workers the s i t u a t i o n and having them work with you on the schedule. 1 . . . . 2 . . . . 3 . . . . 4 . . . . 5 . . . . 6 . . . . 7 very u n l i k e l y moderately l i k e l y very l i k e l y Simply ass ign the times that each can break to avoid any problems. 1 . . . . 2 . . . . 3 . . . . 4 . . . . 5 . . . . 6 . . . . 7 very u n l i k e l y moderately l i k e l y very l i k e l y F ind out from someone i n author i ty what to do or do what was done i n the past . 1 . . . . 2 . . . . 3 . . . . 4 . . . . 5 . . . . 6 . . . . 7 very u n l i k e l y moderately l i k e l y very l i k e l y 112 5. A c lose f r i e n d of yours has been moody l a t e l y , and a couple of times has become very angry with you over "noth ing" . You might: Share your observat ions with him and t ry to f i n d out what i s going on fo r him. 1 . . . . 2 . . . . 3 . . . . 4 . . . . 5 . . . . 6 . . . . 7 very u n l i k e l y moderately l i k e l y very l i k e l y Ignore i t because the re 's not much you can do about i t anyway. 1 . . . . 2 . . . . 3 . . . . 4 . . . . 5 6 . . . . 7 very u n l i k e l y moderately l i k e l y very l i k e l y T e l l him that you ' re w i l l i n g to spend time together i f and only i f he makes more e f f o r t to c o n t r o l h imse l f . 1 . . . . 2 . . . . 3 . . . . 4 . . . . 5 . . . 6 . . . . 7 very u n l i k e l y moderately l i k e l y very l i k e l y 113 6. You have jus t received the r e s u l t s of a test you took, and you discovered that you d id very poor ly . Your i n i t i a l react ion i s l i k e l y to be: "I c a n ' t do anything r i g h t " , and f e e l sad. 1 . . . . 2 . . . . 3 . . . . 4 . . . . 5 . . . . 6 . . . . 7 very u n l i k e l y moderately l i k e l y very l i k e l y "I wonder how i t i s I d id so p o o r l y " , and f e e l d isappo in ted . 1 . . . . 2 . . . . 3 . . . . 4 . . . . 5 . . . . 6 . . . . 7 very u n l i k e l y moderately l i k e l y very l i k e l y "That s tup id test doesn' t show anyth ing" , and f e e l angry. 1 . . . . 2 . . . . 3 . . . . 4 . . . . 5 . . . . 6 . . . . 7 very u n l i k e l y moderately l i k e l y very l i k e l y 7 . You have been inv i ted to a large party where you know very few people As you look forward to the evening you would l i k e l y expect that : Y o u ' l l t ry to f i t i n with whatever i s happening i n order to have a good time and not look bad. 1 . . . . 2 . . . . 3 . . : . 4 . . . . 5 . . . . 6 . . . . 7 very u n l i k e l y moderately l i k e l y very l i k e l y Y o u ' l l f i n d some people with whom you can r e l a t e . ' 1 . . . . 2 . . . . 3 . . . . 4 . . . . 5 . . . . 6 . . . . 7 very u n l i k e l y moderately l i k e l y very l i k e l y Y o u ' l l probably f e e l somewhat i s o l a t e d and unnot iced. 1 . . . . 2 . . . . 3 . . . . 4 . . . . 5 . . : . 6 . . . . 7 very u n l i k e l y moderately l i k e l y very l i k e l y 115 8. You are asked to plan a p icn ic for yourse l f and your fe l low employees. Your s t y l e for approaching th is project could most l i k e l y be charac ter i zed as : Take charge: that i s , you would make most of the major dec is ions y o u r s e l f . 1 . . . . 2 . . . . 3 . . . . 4 . . . . 5 . . . . 6 . . . . 7 very u n l i k e l y moderately l i k e l y very l i k e l y Follow- precedent: you ' re not r e a l l y up to the task so you'd do i t the way i t ' s . b e e n done before . 1 . . . . 2 . . . . 3 . . . . 4 . . . . 5 . . . . 6 . . . . 7 very u n l i k e l y moderately l i k e l y very l i k e l y Seek p a r t i c i p a t i o n : get inputs from others who want to make them before you make the f i n a l p lans . 1 . . . . 2 . . . . 3 . . . . . 4 . . . . 5 . . . . 6 . . . . 7 very u n l i k e l y moderately l i k e l y very l i k e l y 116 9. R e c e n t l y a p o s i t i o n opened up a t your p l a c e of work that c o u l d have meant a promotion f o r you. However, a person you work w i t h was o f f e r e d the j o b r a t h e r than you. In e v a l u a t i n g the s i t u a t i o n , you are l i k e l y to t h i n k : You d i d n ' t r e a l l y e xpect the j o b ; you f r e q u e n t l y get passed o v e r . 1 . . . . 2 . . . . 3 . . . . 4 . . . . 5 . . . . 6 . . . . 7 v e r y u n l i k e l y m oderatley l i k e l y v e r y l i k e l y The o t h e r person p r o b a b l y " d i d the r i g h t t h i n g s " p o l i t i c a l l y t o get the j o b . 1 . . . . 2 . . . . 3 . . . . 4 . . . . 5 . . . . 6 . . . . 7 v e r y u n l i k e l y m oderately l i k e l y v e r y l i k e l y You would p r o b a b l y take a l o o k a t f a c t o r s i n your own performance t h a t l e a d you t o be passed o v e r . 1 . . . . 2 v e r y u n l i k e l y 3 . . . . 4 . . . . 5 m o d e r a t e l y l i k e l y 6 . . . . 7 v e r y l i k e l y 117 10. You are embarking on a new career . The most important cons iderat ion i s l i k e l y to be: Whether you can do the work without get t ing i n over you head. 1 . . . . 2 . . . . 3 . . . . 4 . . . . 5 . . . . . 6 . . . . 7 very u n l i k e l y moderately l i k e l y very l i k e l y How in teres ted you are i n that kind of work. 1 . . . . 2 . . . . 3 . . . . 4 . . . . 5 . . . . 6 . . . . 7 very u n l i k e l y moderately l i k e l y very l i k e l y Whether there are good p o s s i b i l i t i e s for. advancement. 1 . . . . 2 . . . . 3 . . . . 4 . . . . 5 . . . . 6 . . . . 7 very u n l i k e l y moderately l i k e l y very l i k e l y 11.8 11. A woman who works f o r you has g e n e r a l l y done an adequate j o b . However, f o r the pa s t two weeks her work has not been up to par and she appears to be l e s s a c t i v e l y i n t e r e s t e d i n h e r work. Your r e a c t i o n i s l i k e l y to be: T e l l h e r t h a t h e r work i s below what i s ex p e c t e d and t h a t she should s t a r t w orking h a r d e r . 1 . . . . 2 . . . . 3 . . . . A . . . . 5 . . . . 6 . . . . 7 v e r y u n l i k e l y moderately l i k e l y v e r y l i k e l y Ask h e r about the problem and l e t h e r know you a r e a v a i l a b l e t o h e l p work i t o u t . 1 . . . . 2 . . . . 3 . . . . 4 . . . . 5 . . . . 6 . . . . 7 v e r y u n l i k e l y moderately l i k e l y v e r y l i k e l y I t ' s h a r d t o know what t o do to get h e r s t r a i g h t e n e d o u t . 1 . . . . 2 . . . . 3 . . . . 4 . . . . 5 . . . . 6 . . . . 7 v e r y u n l i k e l y m o d e r a t e l y l i k e l y v e r y l i k e l y 119 12. Your company has promoted you to a pos i t i on i n a c i t y far from your present l o c a t i o n . As you think about the move you would probably: Fee l interes ted i n the new challenge and a l i t t l e nervous at the same time. 1 . . . . 2 . . . . . 3 . . . . A . . . . 5 . . . . 6 . . . . 7 very u n l i k e l y moderately l i k e l y very l i k e l y Fee l exci ted about the higher status and s a l a r y that i s involved . 1 . . . . 2 . . . . 3 . . . . 4 . . . . 5 . . . . 6 . . . . 7 very u n l i k e l y moderately l i k e l y very l i k e l y Fee l s tressed and anxious about the upcoming changes. 1 . . . . 2 . . . . 3 . . . . 4 . . . . 5 . . . . . 6 . . . . 7 very u n l i k e l y moderately, l i k e l y - very l i k e l y 120 Name or Code: : Sex: M F Date: " I n d i v i d u a l Sty les Response Form 1. a 2. a 3 • a_ b b b c c c 4. a 5. a 6. a_ b b b c c c 7. a 8. a 9. a_ b b b c c_ c_ 10. a 11. a 12. a_ b b b c c c Name or Code: / t - ^ ^ p -Sex: M F Date: 121 I n d i v i d u a l Sty les Response Form 1. X 4. a _ j T _ 5. b ^ 7. a 8. b 10. a _ J l b / ? c £ 11. 3. a ^ c £ c / / a ^ 6. a b X b c & c £ a £ 9. a b J = b ^  = A e A a <? 12. a b 4 b a c r Appendix O Hopkins Symptom Checklist (HSCL) (Derogatis, Lipman, Rickels, Uhlenhuth, & Covi, 1974) *45 items were extracted from the 58-item self-report checklist Please check appropriate number for each question # SCALE: 1 - 2 - 3 - 4 Not Extremely at all distressful "I tend to experience " 1 - 2 - 3 -4 0) headaches 1 - 2 - 3 - 4 (2) nervousness or shakiness inside 1 - 2 -3 - 4 (3) faintness or dizziness 1 - 2 -3 - 4 (4) loss of sexual interest or pleasure 1 - 2 -3 - 4 (5) feeling critical of others 1 - 2 -3 - 4 (6) trouble remembering things 1 -2 -3 - 4 (7) worried about sloppiness or carelessness 1 -2 -3 - 4 (8) feeling easily annoyed or irritated 1 -2 - 3 -4 (9) pains in the heart or chest 1 - 2 -3 - 4 (10) feeling low in energy or slowed down 1 - 2 -3 - 4 (11) thoughts of ending your life 1 - 2 -3 - 4 (12) trembling 1 - 2 -3 - 4 (13) poor appetite 1 - 2 - 3 -4 (14) crying easily 1 - 2 - 3 - 4 (15) a feeling of being trapped or caught 1 - 2 - 3 - 4 (16) suddenly scared for no reason 1 - 2 -3 - 4 (17) temper outbursts you couldn't control 1 - 2 - 3 - 4 (18) blaming yourself for things 1 - 2 - 3 - 4 (19) pains in the lower part of your back 1 - 2 -3 - 4 (20) feeling blocked/stymied In getting things done 1 - 2 -3 - 4 (21) feeling lonely 1 - 2 -3 - 4 (22) feeling blue 1 - 2 - 3 - 4 (23) worrying or stewing about things 1 - 2 - 3 - 4 (24) feeling no interest in things 1 - 2 -3 - 4 (25) feeling fearful 1 - 2 -3 - 4 (26) your feelings being easily hurt 1 - 2 -3 - 4 (27) feeling others do not understand you or are unsympathetic 1 - 2 -3 - 4 (28) feeling that others are unfriendly or dislike you 1 - 2 - 3 - 4 (29) having to do things very slowly in order to be sure you are doing them right 1 - 2 - 3 - 4 (30) heart pounding or racing 1 -2 -3 -4 (31) feeling inferior to others 1 - 2 -3 - 4 (32) soreness of your muscles 1 -2 -3 -4 (33) having to check and double check what you do 1 - 2 -3 -4 (34) difficulty making decisions 1 -2 -3 -4 (35) trouble getting your breath 1 - 2 -3 -4 (36) hot or cold spells 1 - 2 -3 -4 (37) having to avoid certain places because they frighten you 1 - 2 -3 -4 (38) your mind going blank 1 -2 -3 -4 (39) numbness or tingling in parts of your body 1 - 2 - 3 -4 (40) a lump in your throat 1 - 2 - 3 -4 (41) feeling hopeless about the future 1 - 2 -3 - 4 (42) trouble concentrating 1 - 2 -3 -4 (43) weakness in parts of your body 1 - 2 -3 -4 (44) feeling tense or keyed up 1 - 2 -3 -4 (45) heavy feelings in your arms or legs Appendix P Eating Attitude Test (EAT) (Garner & Garfinkel, 1979) Instruction Please place an (X) under the column which applies best to each or the numbered statements. All of the results will be strictly confidential. Most of the questions directly relate to food or eating, although other types of questions have been included. Please answer each question carefully. Thank you. c u </> e : > > o S C — u < > 1. Like eating with other people. ( ) ( ) 2. Prepare foods for others but do not eat what I cook. ( ) ( ) 3. Become anxious prior to eating. ( ) ( ) 4. Am terrified about being overweight. ( ) ( ) 5., Avoid eating when I am hungry. ( ) ( ) 6. Find myself preoccupied with food. ( ) ( ) 7. Have gone on eating binges where I feel that I may not be able to stop. ( ) ( ) 8. Cut my food into small pieces. ( ) ( ) 9. Aware of the calorie content of foods that I eat. ( ) ( ) 10. Particularly avoid foods with a high carbohydrate content (e.g. bread, pota-toes, rice, etc). ( ) ( ) 11. Feel bloated after meals. ( ) ( ) 12. Feel that others would prefer if I ate more. ( ) ( ) 13. Vomit after! have eaten. ( ) ( ) 14. Feel extremely guilty after eating. ( ) ( ) 15. Am preoccupied with a desire to be thinner. ( ) ( ) 16. Exercise strenuously to burn off calo-ries. ( ) ( ) 17. Weigh myself several times a day. ( ) ( ) 18. Like my clothes to fit tightly. ( ) ( ) 19. Enjoy eating meat. ( ) ( ) 20. Wake up early in the morning. ( ) ( ) 21. Eat the same foods day after day. ( ) ( ) 22. Think about burning up calories when I exercise. ( ) ( ) 23. Have regular menstrual periods. ( ) ( ) 24. Other people think that I am too thin. ( ) ( ) 25. Am preoccupied with the thought of having fat on my body. ( ) ( ) 26. Take longer than others to eat my meals. ( ) ( ) 27. Enjoy eating at restaurants. ( ) ( ) 28. Take laxatives. ( ) ( ) 29. Avoid foods with sugar in them. ( ) ( ) 30. Eat diet foods. ( ) ( ) 31. Feel that food controls my life. ( ) ( ) 32. Display self control around food. ( )• ( ) 33. Feel that others pressure me to eat. ( ) ( ) 34. Give too much time and thought to food. ( ) ( ) 35. Suffer from constipation. ( ) ( ) 36. Feel uncomfortable after eating sweets ( ) ( ) 37. Engage in dieting behavior. ( ) ( ) 38. Like my stomach to be empty. ( ) ( ) 39. Enjoy trying new rich foods. ( ) ( ) 40. Have the impulse to vomit after meals. ( ( ( ( e 3 E E o at > V Z ( ) ( ) ( ) ( ) Append ix Q Means and Standard Deviations Across Groups for Items 1 - 90 on Dream Rating Scale 127 Item on Dream Rating Scale ED Non-ED t-value P-1. Whatever I do I won't succeed M 0.39 0.05 3.3 .003 SD 0.33 0.08 2. I may succeed.but change is slow M 0.09 0.03 1.72 .101 SD 0.10 0.06 3. I can only succeed with help M 0.21 0.05 1.75 .095 SD 0.30 0.07 4. Struggling/screaming to no effect M 0.21 0.02 2.04 .054 SD 0.31 0.04 5. Vomiting M 0.02 0.01 0.62 n/s SD 0.05 0.03 6. Taking laxatives M 0.02 0.00 0.96 n/s SD 0.07 0.00 7. Endless waiting M 0.01 0.00 1.41 n/s SD 0.03 0.00 -8. Anger M 0.36 0.15 1.95 .065 SD 0.32 0.17 9. Anxious/tense M 0.11 0.09 0.29 n/s SD 0.12 0.13 10. Abandoned M 0.00 0.00 0 n/s SD 0.00 0.00 11. Bad M 0.02 0.04 -1.02 n/s SD 0.04 0.08 12. Betrayed M 0.01 0.02 -0.82 n/s SD 0.03 0.05 13. Confused M 0.07 0.08 -0.14 n/s SD 0.07 0.09 14. Desperation M 0.05 0.01 1.58 n/s SD 0.07 0.03 15. Disappointed M 0.07 0.03 1.09 n/s SD 0.10 0.04 16. Disgusted/repulsed M 0.05 0.04 -0.25 n/s SD 0.09 0.05 17. Disliked M 0.01 0.02 -0.77 n/s SD 0.02 0.04 18. Embarrassment/humiliation M 0.07 0.07 0.02 n/s SD 0.10 0.13 19. Empty M 0.02 0.00 1.37 n/s SD 0.05 0.00 20. Exposed/vulnerable M 0.03 0.00 2.18 .041 SD 0.04 0.00 21. Fear M 0.33 0.27 0.59 n/s SD 0.28 0.23 22. Frantic M 0.02 0.03 -0.37 n/s SD 0.04 0.12 23. Frustration M 0.09 0.05 0.99 n/s SD 0.11 0.09 128 Item on Dream Rating Scale ED Non-ED t-value P-24. Grief M 0.02 0.00 1.34 n/s SD 0'.05 0.00 25. Guilt M 0.10' 0.02 2.42 .025 SD 0.10 0.04 26. Hate M 0.05 0.02 0.88 n/s SD 0.09 0.06 27. Helplessness/powerlessness M 0.06 0.01 1.3 n/s SD 0.11 0.03 28. Hopeless M 0.01 0.01 0.24 n/s SD 0.04 0.03 29. Horrified M 0.00 0.01 -1.05 n/s SD 0.00 0.18 30. Hostility M 0.04 0.01 0.95 n/s SD 0.10 0.04 31. Hurt M 0.04 0.08 -0.8 n/s SD 0.09 0.15 32. Impatient M 0.01 0.01 0.55 n/s SD 0.05 0.02 33. Irritated M 0.01 0.01 0.57 n/s SD 0.03 0.02 34. Isolated/separated M 0.03 0.01 1.29 n/s SD 0.07 0.02 35. Jealousy M 0.02 0.03 -0.32 n/s SD 0.05 0.06 36. Lonely M 0.03 0.03 0.29 n/s SD 0.05 0.06 37. Lost M 0.02 0.03 -0.34 n/s SD 0.05 0.11 38. Misunderstood M 0.01 0.00 0.96 n/s SD 0.03 0.00 39. Overwhelmed M 0.01 0.00 0.96 n/s SD 0.03 0.00 40. Out of control M 0.01 0.01 0.14 n/s SD 0.02 0.02 41. Panic M 0.12 0.04 1.41 n/s SD 0.16 0.10 42. Sadness M 0.14 0.10 0.53 n/s SD 0.13 0.19 43. Shock M 0.07 0.04 0.5 n/s SD 0.14 0.07 44. Suicidal/wanting to die M 0.03 0.00 1.38 n/s SD 0.07 0.00 45. Terror M 0.02 0.02 -0.33 n/s SD 0.04 0.08 129 Item on Dream Rating Scale ED Non-ED t-value P-46. Trapped M 0.01 0.05 -1.12 n/s SD 0.03 0.12 47. Upset/unhappy M 0.18 0.11 0.94 n/s SD 0.22 0.15 48. Unloved M 0.05 0.00 1.9 .071 SD 0.09 0.00 49. Worry M 0.05 0.03 0.67 n/s SD 0.07 0.06 50. Imprisonment of dreamer M 0.07 0.00 2.29 .032 SD 0.10 0.00 51. Having difficulty breathing M 0.01 0.00 1.37 n/s SD 0.03 0.00 52. Dreamer suffocating M 0.02 0.01 0.89 n/s SD 0.05 0.02 53. Dreamer/dream figure trapped M 0.07 0.08 -0.3 n/s SD 0.09 0.18 54. Dreamer held against will M 0.08 0.00 1.92 .069 SD 0.13 0.00 55. Being forced to do something M 0.07 0.01 1.97 .062 SD 0.10 0.03 56. Aggressive acts by food M 0.04 0.00 1.31 n/s SD 0.10 0.00 57. Food M 0.25 0.16 1.27 n/s SD 0.22 0.10 58. Food-related incident M 0.22 0.14 1.28 n/s SD 0.19 0.11 59. Food-related objects M 0.05 0.08 -0.93 n/s SD 0.06 0.08 60. Food-related places M 0.19 0.20 -0.04 n/s SD 0.28 0.15 61. Food-related people M 0.04 0.03 0.39 n/s SD 0.08 0.06 62. Non-food in digestive tract M 0.01 0.01 0.55 n/s SD 0.05 0.01 63. Inaccessible food M 0.01 0.01 0.05 n/s SD 0.04 0.02 64. Unable to get enough food M 0.03 0.02 0.44 n/s SD 0.05 0.06 65. Cutting/deliberately injuring self M 0.01 0.00 0.96 n/s SD 0.02 0.00 66. Attempting/committing suicide M 0.01 0.00 0.96 n/s SD 0.02 0.00 67. Glass breaking M 0.00 0.00 0 n/s SD 0.00 0.00 68. Bombs exploding/about to explode M 0.01 0.04 -1.49 n/s SD 0.02 0.07 130 Item on Dream Rating Scale ED Non-ED t-value P-69. Collapsing foundations/tunnels M 0.02 0.00 1.4 n/s SD 0.04 0.00 70. Dreamer attacking person etc. M 0.10 0.05 0.94 n/s SD 0.15 0.12 71. Dream figure victim of violence M 0.20 0.10 1 n/s SD 0.28 0.16 72. Scenes of violent catastrophe M 0.09 0.03 0.73 n/s SD 0.29 0.05 73. Images of very fat people M 0.03 0.02 0.57 n/s SD 0.08 0.05 74. Images of very thin people M 0.09 0.00 2.11 .047 SD 0.15 0.00 75. Negative reaction to weight gain M 0.06 0.00 2.19 .040 SD 0.10 0.00 76. Positive reaction to weight loss M 0.02 0.02 0.15 n/s SD 0.06 0.06 77. Sense of weightlessness M 0.03 0.02 0.35 n/s SD 0.10 0.04 78. Watched as if guilty/inadaquate M 0.15 0.02 2.55 .019 SD 0.15 0.06 79. Caught doing something socially M 0.05 0.07 -0.36 n/s unacceptable SD 0.08 0.17 80. Feeling spied on, or continually M 0.05 0.04 0.31 n/s watched SD 0.06 0.08 81. Eyes watching dreamer M 0.00 0.01 -1.05 n/s SD 0.00 0.03 82. Someone going through dreamer/ M 0.02 0.02 0.08 n/s dream figure's private things SD 0.06 0.05 83. Chased with no escape M 0.06 0.01 1.67 .111 SD 0.09 0.02 84. Dreamer being attacked M 0.26 0.03 3.25 .004 SD 0.23 0.05 85. Ethereal beings M 0.02 0.01 0.89 n/s SD 0.05 0.02 86. Dreamer in frightening situation M 0.10 0.07 0.44 n/s of impersonal nature e.g flood SD 0.14 0.18 87. Huge or monstrous dream figures M 0.04 0.01 1.2 n/s SD 0.09 0.04 88. Injured arms and/or legs M 0.08 0.01 1.32 n/s SD 0.15 0.04 89. Dreamer/dream figures bleeding M 0.03 0.05 -0.58 n/s SD 0.07 0.12 90. Toilet images M 0.01 0.02 -0.67 n/s SD 0.02 0.06 Appendix R Subject Profiles for eating-Disordered and Normal Groups Identifying letters form A to L were given to ED subjects M to W were given to Non-ED subjects. Individual Demographics, EAT, GCOS & HSCL Scores of Eating-Disordered Subjects Subject Type of Eating Disorder Length 3 In-patient Out-patient Rx Rx No Rx EAT GCOS Impersonal So Ob HSCL In De An A AN 3 X 36 38 14 17 20 23 12 B AN 3 X 87 66 20 25 23 34 22 C AN.BL 4 X 84 55 34 20 20 33 20 D AN.BL 5+ x x b 59 52 25 25 28 40 21 E AN 13+ b X X 89 63 37 32 24 42 24 F BL 10 x b 9 52 13 11 12 14 8 G BL 14 x x b 61 56 23 20 20 29 23 H AN 5-6 x b 92 61 34 24 26 36 18 1 AN.BL 5 X b 90 54 40 20 22 38 25 J BL 5 x c 49 56 20 21 25 35 18 K BL 4 X 44 52 21 14 19 30 14 L AN nk X 60 41 18 11 16 28 11 a: years; Rx: treatment; AN: Anorexia Nervosa; BL: Bulimia; b: > 1 year; c: < 6 mos; nk: not known So: somatic; Ob: obsessive; In: interpersonal sensitivity; De: depression; An: anxiety Individual Demographics, EAT, GCOS & HSCL Scores of Eating-Disordered Subjects Subject History of Psych Rx (y/n) GCOS HSCL EAT Impersonal So Ob In De An M N O P Q R U V W y n n n n n 10 6 3 5 21 11 4 17 16 12 16 50 36 44 23 43 31 35 40 30 44 37 26 15 14 15 16 17 18 24 17 21 21 25 16 12 8 13 10 11 14 9 15 18 16 15 12 8 15 9 11 14 11 16 17 28 18 17 18 20 18 20 21 20 20 17 14 12 10 8 11 10 9 9 11 11 12 y: yes; n: no; So: somatic; Ob: obsessive; In: interpersonal sensitivity; De: depression; An: anxiety 134 Appendix S Dreams of Eating-Disordered Women Suggesting Unmet Needs at an Infantile Stage Subject K: I am about to give birth to a baby. I am lying under a tree with my boyfriend and his mom is standing behind me. Little tomatoes were falling. She is telling me which tomato to choose as my baby. Screw her, I'm having my own baby.... I am very sick - the baby is in my boyfriend's arms. I am not going to die, I just have to get a hold of myself. I want to take care of my baby, but I'm too sick. I feel no pain but I am shaking and sweating. I wish I could stop for a moment. My teeth are chattering. I am being dragged to a bath tub they are filling with water. It is not coming fast enough. I think, "Why the hell didn't they do this before I had the baby. This happens a lot after birth - why didn't they take care of it. My boyfriend's mom doesn't want me to take him - he's her baby. Subject D: (a) I was nursing a baby. It was very comforting to me. But I remember being concerned that my baby wouldn't get enough milk. (b) I had a baby that I was always forgetting. I was leaving it outside and it was getting cold. At one point I had thrown up and felt guilty because I had forgotten my baby again. I remember seeing mom and dad, and wanting them to help me take care of my baby. I felt so guilty and sad for my baby. I wanted to love it so bad, but somehow I just couldn't seem to get things right. Feelings: Scared; guilty; afraid; very sad. Subject J: I'm back cooking french toast downstairs, and the family is upstairs. My mom announces she is going away again in a week. During this time someone is going to have a baby, so I get angry at my mom because she is leaving again and cannot help the woman when her baby is born. I yell and yell at her, and yell that she could twist and break my arm like she always did to get rid of her anger towards me. Feelings: A great deal of ANGER. 135 Subject F: I am an older sister in the family. The father is telling me to put the baby in the refrigerator to put it to bed. At first I did it and it seemed like the normal thing to do, except every time I shut the fridge door, the baby cried. Gradually It occurs to me that putting the baby in the refrigerator is really not the right thing to do, so I quickly take it out. The baby is very tiny, about the size of my fist, and its in a bowl of something like jello. Its almost frozen, but I clear the frozen jello away from its face and its still breathing. Feelings: Very anxious; very afraid; very guilty; sad. 136 Append ix T P r o p o s e d C h a n g e s to Dream Rating Sca le The raters found the format of the dream scale somewhat clumsy, namely, in the inclusion of the "explanations" at the end of the scale, rather than being incorporated into the body of the scale. An amended scale might include the qualifying statements within the categorized items. For example, item 86 as it currently stands reads as "Dreamer in a frightening situation over which she has no apparent control". By including the qualifying statement currently found in "explanations", it would read as "Dreamer in a frightening situation of an impersonal  nature eg. natural disaster, war, collective hostility, which she could have no way of overcoming. Ominous sense of/ threat = P; Presence = EP". Additional psychological themes found by raters were: 1. A need to be special, portrayed by: (a) the dreamer being with somebody famous, either fictional character, movie star or royalty; (b) being a special person such as royalty, fairy tale character (Cinderella at the ball), etc. with everybody paying attention to her; and (c) the mention of a dream figure as somebody special, i.e., the use of the word "special" in connection with a dream person. 2. Feeling isolated or left out, portrayed by images of (a) being excluded in some way, (b) not being heard, no matter how much the dreamer tries to be heard, or (c) stated feelings of isolation. 3. A neurotic sense of power, portrayed by images found in the dreams quoted in chapter 5. The themes of "invasion of privacy" and "a sense of being watched and judged" are insufficiently separate in the dream rating scale as it currently stands. It would appear that the images of "eyes" might be more appropriate in the latter category (see Appendix C). A rater proposed an additional behaviour in one eating-disordered woman's dream as indicating a sense of invasion of privacy, namely "dreamer (repeatedly) trying to hide, but being (repeatedly) found". It seems that a sense of being watched and judged is connected to the experience of shame, which might be a way to separate it from the invasion of privacy images. However, more dreams need to be studied to clarify these two categories. Low perceived self-efficacy. An attitude to be included in this category is "I cannot succeed". It was found that the attitude "I can only succeed if somebody helps me" was insufficient to cover the attitude of utter helplessness, where the dreamer does not even indicate that assistance could save her. An additional image is the "experience of self as thing", such as in being a dot, or a golf ball. Blocked emotions, or the suppression of feelings. A theme occurred in one of the dreams of subject K which appears to indicate the suppression of anger: I am having an argument with my mom. We have hit head on and we are not backing down....My friends are laughing, lighting the hydrogen on the fire. I am angry at my mom and my friends. I overrode my feelings and tried to put out the little flames. After trying for a few seconds, I pick up the old fire extinguisher that is leaking around the lower joint. I wonder whether it will work. It does, and it eventually puts out the flames. My mom is happy I have come to my senses. 137 Images of putting out fires might be taken to mean the suppression of feelings, in this case anger. Obsess ion with weight. It would appear that "body image concerns" would have been a more apt title for this psychological state, as "obsession with weight" restricted the images to weight and shape issues. Hall and van de Castle (1966) include any reference to physical appearance, such as "my hair fell out", under body image concerns. Additional images proposed by the raters to be included in "Body Image Concerns" were: 1. Images referring to facial issues, such as "my teeth fell out", or "the bridge for my teeth broke".. 2. Mention of swelling, in this case, swelling going down so that the bones could be seen again. 3. Mention of the words "ribs" and "bones". Images of dieticians should have been included in the "obsession with weight" category, rather than as "obsession with food". This image only occurred in the dreams of the eating-disordered women. 

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