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Case studies of the bulimic experience 1993

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CASE STUDIES OF THE BULIMIC EXPERIENCE by MICHELLE LOUISE GIBSON B.A., UNIVERSITY OF BRITISH COLUMBIA, 1979 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES DEPARTMENT OF COUNSELLING PSYCHOLOGY We accept this thesis as conforming to the required standard UNIVERSITY OF BRITISH COLUMBIA APRIL, 1993 © M. L. GIBSON, 1993 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. (Signature) Department of cotkiCLNE.) 1yc0,6(--)1 The University of British Columbia Vancouver, Canada Date ^11_4 /(cji3., DE-6 (2/88) ABSTRACT Although reported cases of bulimia are continuing to increase, much about the cause, nature, and treatment of the disorder is still not known. This thesis sought to develop a detailed body of knowledge based on three case studies of the subjective experiences of bulimic women. Three self-selected women from the self-help group, Overeaters Anonymous, volunteered for the study. Participation was contingent upon the completion of a DSM-IIIR symptom checklist identifying substantive amounts of bulimic behavior. Each woman participated in a one-hour case history pre-interview; twelve, one-hour sessions; and a one-hour follow-up interview six weeks after sessions terminated. The twelve sessions were intended to provide a safe environment in which to explore the bulimic experience aided by the use of art therapy and guided imagery exercises where deemed appropriate by both counsellor and client. Four findings in the study validated existing phenomenological research. They were: fear of losing control leading to feelings of abandonment; the use of bulimia as a protective shield; a desire to purify; and global and food-specific shame and guilt. Nine themes extended findings from previous research. They were: a sense of Godlessness, self-doubt, feeling like a 'freak', opposing attitudes/desires on a single issue, self-pity, disenchantment with the perceived female role, exceptional concern for the perceived down-trodden, the memory of an unsafe childhood, and fear of intimacy. A final finding extended research through charting an overall pattern of experience of the bulimic woman's journey of healing. Participants reported positive benefits from the use of guided imagery in that they felt it enabled them to access previously inaccessible thoughts and feelings. These findings may be useful for both theoretical and practical application. TABLE OF CONTENTS AUTHORIZATION ABSTRACT TABLE OF CONTENTS LIST OF FIGURES^ vii ACKNOWLEDGEMENTS xiv I. Introduction^ 1 Statement of the Problem^ 1 Research Question 1 Rationale^ 2 Definition of Major Terms^ 3 II. Literature Review 5 Prevalence^ 5 Biological Factors 6 Familial Factors^ 7 Sexual Abuse Factors 8 Sociocultural Factors^ 9 Treatment Approaches 11 Use of Imagery^ 13 Phenomenological Studies^ 15 Overall Summary of the Literature Review^ 17 III. Method^ 18 Design 18 Participants^ 20 Cynthia Background^ 20 Sonya Background 20 Alison Background^ 21 Counselling Program 21 Sources of Information^ 23 Audiotapes and Transcriptions 23 Imagery^ 23 Therapist's Log 24 Reflective Discussion^ 24 Opportunistic Sources of Evidence^ 24 Telephone Debriefings^ 24 Procedures^ 25 Analysis 25 IV. Case studies^ 29 Cynthia^ 29 Session 1 ^ 29 Therapist's Log, Session 1 ^ 32 Session 2 34 Therapist's Log, Session 2 39 iv Telephone Debriefing, Week 1^ 40 Session 3 Therapist's Log, Session 3 Session 4 Therapist's Log, Session 4 Telephone Debriefing, Week 2 Session 5 Therapist's Log, Session 5 Session 6 Therapist's Log, Session 6 Telephone Debriefing, Week 3 Session 7 Therapist's Log, Session 7 Session 8 Therapist's Log, Session 8 Telephone Debriefing, Week 4 Session 9 Therapist's Log, Session 9 Session 10 Therapist's Log, Session 10 Telephone Debriefing, Week 5 Session 11 Therapist's Log, Session 11 Session 12 Therapist's Log, Session 12 Telephone Debriefing, Week 6 40 42 43 44 45 45 47 48 50 50 50 52 52 56 56 57 58 58 61 61 61 64 64 67 68 V Sonya^ 68 Session 1 Therapist's Log, Session 1 Session 2 Therapist's Log, Session 2 Telephone Debriefing, Week 1 Session 3 Therapist's Log, Session 3 Session 4 Therapist's Log, Session 4 Telephone Debriefing, Week 2 Session 5 Therapist's Log, Session 5 Session 6 Therapist's Log, Session 6 Telephone Debriefing, Week 3 Session 7 Therapist's Log, Session 7 Session 8 Therapist's Log, Session 8 Telephone Debriefing, Week 4 Session 9 Therapist's Log, Session 9 Session 10 Therapist's Log, Session 10 Telephone Debriefing, Week 5 Session 11 Therapist's Log, Session 11 68 71 73 75 75 76 78 78 79 80 80 81 82 84 85 85 88 88 89 89 89 90 91 91 92 92 93 vi Session 12^ 93 Therapist's Log, Session 12^ 94 Telephone Debriefing, Week 6 95 Alison^ 95 Session 1^ 95 Therapist's Log, Session 1^ 100 Session 2 101 Therapist's Log, Session 2 106 Telephone Debriefing, Week 1^ 107 Session 3^ 108 Therapist's Log, Session 3 110 Session 4 110 Therapist's Log, Session 4^ 112 Telephone Debriefing, Week 2 113 Session 5^ 113 Therapist's Log, Session 5^ 115 Session 6 116 Therapist's Log, Session 6 118 Telephone Debriefing, Week 3^ 119 Session 7^ 119 Therapist's Log, Session 7 121 Session 8 121 Therapist's Log, Session 8^ 123 Telephone Debriefing, Week 4 123 Session 9^ 123 Therapist's Log, Session 9^ 125 Session 10 125 Therapist's Log, Session 10 127 Telephone Debriefing, Week 5^ 127 VII Session 11^ 128 Therapist's Log, Session 11^ 130 Session 12 130 Therapist's Log, Session 12 132 Telephone Debriefing, Week 6^ 133 Follow-up Results^ 133 Cynthia^ 133 Sonya 134 Alison^ 135 V. COMPARATIVE ANALYSES OF THE CASES^ 136 Aspects of ways of construing and experiencing 136 Fear of losing control leading to feelings of abandonment^136 The use of bulimia as a protective shield^ 137 A desire to purify^ 139 Global and food-specific shame and guilt^ 139 A sense of Godlessness^ 140 Self-doubt^ 143 Feeling like a 'freak'^ 143 Opposing attitudes/desires on a singe issue^ 144 Self-pity^ 144 Disenchantment with the perceived female role^ 146 Exceptional concern for the perceived down-trodden 147 The memory of an unsafe childhood^ 148 viii Fear of Intimacy^ 149 Patterns of Experience 150 Destructive Phase^ 150 Channelling Behavior^ 151 Restorative Drama Phase 151 Transitional Drama Phase^ 153 Results of Transformation 154 Summary of Transformation^ 155 VI. DISCUSSION^ 156 Statement of Findings 156 Limitations^ 156 Implications for Theory^ 158 Major Findings 158 A Common Orientation^ 160 Minor Findings 162 Implications for Practice^ 164 Implications for Future Research 165 Summary^ 169 VII. REFERENCES^ 170 APPENDICES 177 ix List of Figures CYNTHIA Figure C1.1. Kite.^ 179 Figure C1.2. The coffin. 180 Figure C1.3. Living room.^ 181 Figure C1.4. How the world sees me.^ 182 Figure C1.5. What I see when I look in the mirror.^ 183 Figure C1.6. My Inner Healer^ 184 Figure C2.1. The Separation. 185 Figure C2.2. The Path.^ 186 Figure C3.1. The grey filter mask.^ 187 Figure C3.2. Closeup of the filter. 188 Figure C5.1. The feeling of being a prostitute^ 189 Figure C5.2. No.^ 190 Figure C8.1. Red heart. 191 Figure C8.2. Flower behind bars.^ 192 Figure C8.3. Third drawing. 193 Figure C10.1. The Warrior.^ 194 Figure C12.1. How the world sees me.^ 195 Figure C12.2. What I see when I look in the mirror.^ 196 Figure C12.3. My inner healer.^ 197 x List of Figures SONYA Figure S1.1. Poppa.^ 198 Figure S1.2. My kids. 199 Figure S1.3. Vacationland.^ 200 Figure S1.4. How the world sees me.^ 201 Figure S1.5. What I see when I look in the mirror.^ 202 Figure S1.6. My inner healer.^ 203 Figure S2.1. Male and female. 204 Figure S4.1. Yellow.^ 205 Figure S6.1. The heart. 206 Figure S9.1. Little black devil.^ 207 Figure S12.1. How the world sees me. 208 Figure S12.2. What I see when I look in the mirror.^ 209 Figure S12.3. My inner healer.^ 210 xi List of Figures ALISON Figure A1.1. Confusion.^ 211 Figure A1.2. Isolation. 212 Figure A1.3. Bird.^ 213 Figure A1.4. How the world sees me.^ 214 Figure A1.5. What I see when I look in the mirror.^ 215 Figure A1.6. My inner healer.^ 216 Figure A2.2. The AA and the OA Alison.^ 217 Figure A2.2. Black Self.^ 218 Figure A2.3. Feelings for parents.^ 219 Figure A3.1. The yelling man. 220 Figure A3.2. The protector Aura.^ 221 Figure A4.1. Male and female. 222 Figure A4.2. Twelve year old.^ 223 Figure A5.1. Terror and vertigo. 224 Figure A5.2. My spirituality.^ 225 Figure A5.3. The nagging doubt. 226 Figure A6.1. What I lose by giving up binging.^ 227 Figure A7.1. Thick wall.^ 228 Figure A9.1. The screen. 229 Figure A10.1. Desirable characteristic.^ 230 Figure A11.1. The seagull.^ 231 xii Figure Al2.1. How the world sees me.^ 232 Figure Al2.2. What I see when I look in the mirror.^ 233 Figure Al2.3. My inner healer.^ 234 3dii ACKNOWLEDGEMENTS Dr. Larry Cochran for his patience, support, and guidance. Drs. Ron Manley and John Allan for their thoughtful contributions. Dr. Jim Frankish for his moral support. I would also like to add a note regarding the personal motivation behind this thesis. I was anorexic for two years and bulimic for eight. I worked with several therapists based in a variety of therapeutic paradigms. Two therapists were truly instrumental in my recovery. One utilized guided imagery. The other encouraged me to draw. I have married these approaches and changed them considerably for this study, but I owe the genesis of this thesis to Eva Di Casmirro in Vancouver and Patti Parry in Toronto. xiv I. Introduction Statement of the Problem Reports of bulimia were once so rare that it was considered a medical curiosity. In fact, it was not officially classified as a separate psychiatric disorder until the publication of the DSM-III in 1980. However, over the past 15 years, the reported incidence and prevalence of bulimia in the western world has increased (Bendfeldt-Zachrisson, 1992). During the period of 1979-1987, the Stanford Eating Disorder Clinic's reported annual number of cases of bulimia rose from 10 to over 200 (Agras, 1987). By 1990, Palmer reported that a "near-epidemic proportion" (p. 12) of 1.2 million adolescent/young adult females in the U.S. had an eating disorder. Some researchers, such as Wolf (1991), have gone so far as to suggest that the norm for young, middle-class American women, "is to be a sufferer from some form of eating disease" (p. 182). Bulimia has important relations to a number of other prevalent physical and psychological issues including: depression (Hartmann, Herzog & Drinkmann, 1992), sexual abuse (Thackwray, 1991), substance abuse (Bulik, 1992), and personality disorders (Rubenstein, Pigott, L'Heureux, Hill & Murphy, 1992). Its connection to other phenomenon, increasing reports of bulimia, and a general lack of information or consensus regarding many facets of the disorder, support the need for more study (Williamson, 1990). Research Question Bulimia is an increasing problem in western civilization and yet much about the disorder remains a mystery. Facilitated through the use of imagery., this thesis aimed to shed additional light on the enigma of bulimia through intimately exploring how three bulimic women interpreted their world: their motives, life-historical content, and perceptions. Specifically, this thesis attempted to answer the question: What is the meaning of the female experience of bulimia? 1 Rationale Rowen (1991) suggests that insufficient approaches and methodologies, and controversy among researchers, has undermined investigators' abilities to study the essence of binge eating. Nosological problems in the literature have outlined the need to better understand the underpinnings of the multi-faceted life experience of the bulimic. Ford (1985) found major differences among bulimics who were fasters, vomiters or laxatives abusers. The laxative abusers, for example, showed significantly more overall distress than the vomiters and fasters. To that end, possible subtyping options for the diagnosis of bulimia have been suggested for incorporation in DSM-IV (Mitchell, 1992; Spitzer & Devlin, 1992). This study sought to add to our understanding of bulimia by exploring bulimic women's subjective experiences within the framework of a treatment program. A treatment program was employed, rather than a series of in-depth interviews, to provide as much opportunity as possible for each of the women to experience change. Change is viewed by many (Arkowitz, 1989; Bronfenbrenner, 1979; Guidano and Liotti, 1983) as an effective method by which much new information can be acquired and processed. Change was encouraged throughout treatment using an eclectic variety of paradigms in response to each of the individual women's ways of being. These various responses grew out of a core approach which was a client-centered foundation of unconditional positive regard. From that foundation, Egan-model (1990) problem-managing and opportunity-developing strategies, gestalt role-playing, rational-emotive therapy, and cognitive-behavioral relaxation techniques were all employed accordingly in an effort to respond to the unique nature of each woman. In considering accessing the bulimic woman's thoughts, much of the information collected has concentrated on the explicit mind. Researchers and/or therapists have appealed to a mode of thinking which analyzes, verbalizes, abstracts and makes rational statements based on rational thought (Miller, 1991). Perhaps, the limited success in 2 understanding and treating bulimia has been as a result of eschewing the perceptual, non- verbal implicit world. Guidano and Liotti (1983) suggest that "the information content of imagination is mainly tacit and indirectly noticed by the individual, who would have difficulty in explicating it for himself or herself and for others according to the analytical, sequential, and descriptive terms of language. Precisely because of these features, the imaginal stream can be considered as one of the more characteristic ways in which an individual's tacit self-knowledge is manifested" (p. 77). During the course of treatment the imaginal stream was tapped through the use of both external (art therapy) and internal (guided imagery) imagery. It was hoped that the addition of imagery work would prove to be a valuable component and catalyst in generating insights from the tacit realm into the essence of the bulimic experience. The choice of these two techniques for this study was based on the hypothesis that guided imagery accesses the tacit self (Achterberg, 1985). And drawing may function as a bridge (Allan, 1978) by making introspective images visible on paper potentiating explicit analysis and verbalization of implicit material. Definition of Major Terms This section reviews definitions for the following constructs of interest pertaining to this thesis. The definitions include: bulimia, body image, art therapy, the Three Selves Test, and guided imagery. Bulimia nervosa, as defined by DSM-IIIR (American Psychiatric Association, 1987), involves recurrent episodes of binge eating (rapid consumption of a large amount of food in a discrete period of time). It is accompanied by a feeling of lack of control over eating behavior during the eating binges. The person may also engage in self-induced vomiting, use of laxatives or diuretics, strict dieting or fasting, and/or vigorous exercise in order to prevent weight gain. Other diagnostic criteria include a minimum average of two binge 3 eating episodes a week for at least three months, and a persistent over-concern with body shape and weight. The term body image has diverse connotations. For this study it has been defined as a) the way in which our body appears to ourselves (Lacey & Birtchnell, 1986), b) the way in which we take in attitudes and feelings toward the body that occur as individuals view and experience their body in interaction with others across time (Kolb, 1975), and c) a method of perception that has a conscious and unconscious component, the formation of which involves crucial interaction among social, psychological and physiological factors (Schindler, 1935). Art therapy is ostensibly the employment of creative processes in an effort to access and to nurture psychological healing. Defined for this study, it is a colour drawing technique relied upon at relevant points during the therapy session, i.e., draw a picture of your family at the dinner table, as a tool to develop introspective images by making them tangible on paper. The Three Selves Test (TST) (Gibson, 1992) is a treatment and measurement tool designed and operationalized for this study. The TST consisted of clients being asked to draw, and reflect upon, three drawings in this order: A) a picture of "How the world sees me" B) a picture of "What I see when I look in the mirror" C) a picture of "My Inner Healer". Guided imagery is defined as a technique which combines relaxation with relevant conscious information, creativity, and tacit symbols. Ideally, the combination allows images to come forth within the mind of the client which they may chose to share with the therapist for the purposes of exploration and discussion. 4 II. Literature Review This section reviews research as it pertains to the prevalence, possible contributing factors, treatment approaches, body image, art therapy, guided imagery and documented phenomenological experiences of bulimia. Prevalence In spite of increases in reported incidents of bulimia over the past two decades, epidemiological surveys attempting to chart these developments are rare. Reports of incidence/prevalence in populations other than high school or college students are extremely limited (Hart & 011endick, 1985). One general population survey has been conducted. Rand and Kuldau (1992) surveyed 2,115 adults and found prevalences of bulimia in 1.1% of the total sample, and in 4.1% of women aged 18-30 years. Surveys have been hampered, in part, by the nature of the disorder. Depending on how bulimia is defined, published studies have shown that 26%-79% of women, and 41%- 60% of men, report binge eating (Mitchell & Eckert, 1987). It appears that many of the symptoms described by bulimics are also common in the general population. There still exists a lack of consensus regarding which level of eating pathology is the critical point or threshold separating normal eating behaviors from eating disorders. To that end, Fairburn and Beglin (1990) recommend rather than studying the distribution of the disorder, a more important focus is one that concentrates on an examination of the determinants of the entire spectrum of the disorder. An emerging consensus among investigators of bulimia is that it is a multideterminet1 disorder the development and maintenance of which is effected by biological, familial, sexual abuse, and sociocultural factors (Grissett, 1991). 5 Biological factors Proponents of the biological paradigm suggest that there is a direct correlation between the development and maintenance of bulimia and pathophysiology. Explanatory proposals include a lack of glucose homeostasis (Totten, 1990), regulatory dysfunction of the hypothalamus, a possible common etiology between bulimia and affective disorders, and bulimia as a variant or type of seizure disorder (Bendfeldt-Zachrisson, 1992). So far research in these areas, although interesting, is not sufficient to be able to point to a possible primary cause. Evidence of a genetic link between depression and bulimia has been suggested (Agras, 1987), as has a correlation between depression and bulimic symptomatology (Swift & Kahn, 1985). Lee and Rush (1985) suggested that 59% of first-degree relatives of bulimics suffered from affective disorder. Swift and Kahn (1885) found that the higher the depression scores, the more intense the bulimic symptomatology and attitudes. This finding was corroborated by Schlesier-Carter, Hamilton, O'Neil, Lydiard and Malcolm (1989) who provided evidence that bulimics were significantly more depressed than controls and that they showed more maladaptive thinking associated with depression. In spite of substantial research into the connection between depression and bulimia the relationship between depression and bulimia remains poorly understood (Fornari, Kaplan, Sandberg, Matthews, Skolnick, & Katz, 1992). Furthermore, a fair amount of controversy still exists regarding whether depression is a consequence of the eating disorder itself or whether bulimia is subordinated to depression (Bendfeldt-Zachrisson, 1992). A further contributing confound in the debate over the connection between depression and bulimia exists in that greater externality has been associated with greater depression (Benassi & Sweeney, 1988). A recent meta-analytic review (Hartmann et. al., 1992) found that depression and locus of control were consistently and moderately related across studies. There appears to be a correlation between external locus of control and the 6 occurrence of bulimia in women (Shisslak & Pazda, 1990; Leclair, 1984). Bulimic women exhibit a greater external locus of control than non-bulimic women of similar weight levels. Notably, Shisslak and Pazda reported that the highest external locus of control was, like low self-esteem, found among the most underweight bulimics. Familial Factors Another possible determinant which has been considered as a fundamental and/or exacerbating factor in the development and maintenance of bulimia is familial relationships. Families of eating disordered patients tend to have difficulty with boundaries, conflict management, and support for autonomy (Connors & Morse, 1993). Hathaway-Clark (1991) hypothesized that because bulimics tend to be high achievers who struggle with sex role and relationship issues, their fathers may emphasize achievement but be unavailable for a loving relationship. She was, however, unable to demonstrate that father-daughter relationship issues contributed uniquely to symptomatology associated with bulimia. According to Belt (1990), a parental care style of low empathy and high control may be negatively correlated with eating disorder symptomatology. In religious families of bulimics, God was portrayed as a controller, a protector, and a judge; a perception which LavaIlee (1987) associated with both poor self-esteem and guilt feelings in bulimics. Mothers of bulimic women have been cited by Tennessen (1991) as more likely to hold unrealistic expectations regarding their daughters' attractiveness. Grace (1990) suggested that increased bulimic symptoms may result if an affectively unstable daughter is raised by a non-bulimic, narcissistic mother. Grace felt that the daughter's bulimic struggle may represent an effort to achieve independence and a separate identity from her mother. Compared to non-eating disordered women, bulimics perceive significantly less social support from both friends and family along with more negative interactions and conflict, particularly with family members (Grissett, 1991). Global difficulties with interpersonal relationships have been linked with problems in the symbiotic and 7 separation-individuation phase of development. Kramer (1991) suggests that such disturbances play a causal role in the development of bulimia. It may be that the bulimic perceives separation as a form of rejection of her family reflecting problems in "passage out of adolescence and into independent adulthood" (Wooley & Kearney-Cooke, 1986, p. 478). Finally, the presence of siblings may affect the development and maintenance of bulimic behavior. Lewis (1988) found sibling relationships to be an important factor in that bulimia may be used as an indirect expression of affect to a sibling. It may also be used as a means of getting out of a complementary role with a sibling, or as an expression of immobilizing ambivalence in the sibling relationship. Sexual Abuse Factors Another contributing factor in the development and/or maintenance of bulimia may be a history of sexual abuse. Up to 65% of eating disordered patients describe severe sexual or physical trauma as children (Zerbe, 1992). Swirsky (1991) studied the relationship between childhood sexual abuse experiences, dissociation, personality styles, and bulimic experiences in women and found that, although abused bulimics were significantly more dissociative than were non-abused bulimics, there was no relationship between the severity of the bulimia and dissociation. On the other hand, Waller (1992) did find that a bulimic woman with a history of sexual abuse tended to binge, and to a lesser extent, purge, more frequently. Further, he observed that the symptoms of bulimia were exacerbated when the abuse was intrafamilial, involved force, or occurred before the victim was 14 years old. Abused bulimic women demonstrate a higher level of body dissatisfaction, a pronounced experience of feeling fat, and more overall psychological distress than nonabusecl bulimics (Zaslove, 1991). Zerbe (1992) notes that some eating disordered patients may respond to their childhood sexual trauma with sexual promiscuity in adulthood. She suggests that promiscuity serves as a method by which to search for an 8 omnipotent caretaker, to allow the self to be more cohesive, and to avoid fragmentation by merger with another person. In considering the possibility of sexual abuse from an etiological perspective, Connors and Morse (1993) take a more cautious view. They suggest that although for some patients there may be a direct connection between sexual trauma and eating pathology, in general, sexual abuse is best regarded as a risk factor. Sociocultural Factors Another possible determinant of bulimia is the value society places on possessing a thin body type. Thinness is an increasingly socially desirable choice, (Wiseman & Gray, 1992). Wiseman and Gray found that weight lose and exercise articles in women's magazines had increased significantly over a 30 year period meanwhile the body measurements of Playboy magazine centerfolds and Miss America Pageant contestants' for 1979-1988 ranged between 13-19% below the average weight for women in that age group. Agras (1987) speculates that it is this discrepancy between biological reality and social standards that has exacerbated the prevalence of bulimia. Bulimics reason they can become more attractive through losing weight by purging/vomiting (Martin, 1989). If Agras (1987) is correct, it would appear that North America has embraced a certain set of social standards which may be contributing to bulimic behavior with astounding effectiveness. According to Wolf (1990), the growing numbers of eating disordered women in other parts of the western world, like Western Europe and Japan, resemble North American figures from ten years ago. This continent is the dubious worldwide front-runner of eating disorders. Why has North America become such a breeding ground for this disorder? There are several theories. Boskind-Lodahl (1976) initially suggested that women had fallen victim to the media's propagation of very thin cultural models of beauty but she has since rescinded that idea. In more recent years, she has found more differences than similarities 9 among patients and suggests more study is required. Wolf (1990) maintains that "a cultural fixation on female thinness is not an obsession about female beauty but an obsession about female obedience" (p. 187). She suggests that caloric restriction is a means by which to deflate a feminist revolution toward egalitarianism with men. A female desire to be thin may also be reflecting a revolution toward emulating men. As Wooley and Kearney-Cooke (1986) have observed, "this is the first generation of women expected to live a life different from their mother's - a life, instead, like their father's. This change in women's role is probably not independent of the change in preferred body type for women" (p. 478). In fact, the seemingly pandemic rejection of a classically feminine, round, soft, body type in North America may be related to the supposedly lofty financial goals of 'father's' work. Bendfeldt-Zachrisson (1992) speculates that bulimia occurs in advanced capitalistic societies as a means of social distinction. He shores up this suggestion by pointing out that in developing countries, where social class division is dramatic, eating disorders are found even more exclusively among young women of economically powerful families. It may be that bulimia is the result of having moved, by and large, beyond an all- consuming focus on day-to-day survival. Perhaps advanced capitalism has afforded the opportunity for the recognition and growth of a different kind of survival challenge: that of a sort of psychic famine. Woodman (1982) suggests that eating disordered women are battling for a spiritual consciousness through food, using food as a method by which to access emotions. Woodman argues, "it may well be that the numinosity of food and drink reflects the central crisis in our 20th-century culture: the crisis in faith. We live in a predominantly Christian culture which has lost its living connection to the symbolism of wafer and wine. Lacking spiritual sustenance there is genuine hunger and thirst" (p. 28.) 10 Treatment Approaches Treatment approaches to bulimia have largely been either cognitive-behavioral (Schneider & Agras, 1985) or pharmacological (Stewart, Walsh, Wright, Roose & Glassman, 1984). Fairborn (1981) described cognitive-behavioral procedures as attempting to interrupt the bulimic cycle of eating by reinstating normal eating habits while simultaneously challenging accompanying distorted beliefs. Techniques such as contractual agreements or exposure to binge foods under therapist supervision combined with prevention of vomiting have typically been utilized. Some success has been reported with the cognitive-behavioral approach. For example, Wilson and Eldredge (1991) reported significant reductions in binging and purging in 22 patients over 20 sessions of cognitive- behavior therapy (CBT). Although the CBT approach does not render complete recoveries, it is still considered to be the most effective treatment for bulimia to date (Herzog, Keller, Strober, Yeh, & Pal, 1992). There is an increasing trend toward the use of pharmacotherapy for treating bulimics. The pharmacological approach has been based on the hypothesis that bulimia is a form of an affective disorder. Drugs have been employed to reduce depression and anxiety in bulimics. The use of anti-depressants has been met with some success. Stewart, Walsh, Wright, Roose and Glassman (1984) reported that 75% of bulimics treated with either imipramine or monoamine oxidase inhibitors reduced their binge eating. However, withdrawal of medication almost always resulted in relapse. In some cases, relapse occurred despite continuation of the medication. Until recently, one possible impediment to recovery, regardless of the treatment of choice, was considered to be a bulimic with a history of substance abuse. Depending on diagnostic criteria and sampling procedures, substance abuse among the bulimic population has been estimated at as high as 50% as compared to 5% among women in the general population (Strasser, Pike, & Walsh, 1992). However, Strasser et. al. (1992) found that a 11 past history of substance abuse has no implication regarding response to psychotherapeutic or pharmacological treatments for bulimia. No one treatment has yet been devised to enable a person who is experiencing bulimia to successfully recover. Most clinicians do not believe that there is a consensus regarding how to treat eating disordered patients (Herzog et. al, 1992). This impasse is partially a result of the unique complexity of the disorder. Bulimia has strong psychological and physiological components that combine to confound any one therapy. One of the most successful treatment programs to date (Lacey, 1983) attempted to address both components. Lacey used modifications of cognitive-behavioral therapy and "insight" therapy. By the end of 10 weeks, 24 of 30 patients had stopped binging and purging and very little relapse occurred during the 2-year follow-up. The results suggest that the addition of the insight-directed therapy contributed to both greater understanding and to a more positive outcome. Although work such as Lacey's (1983) has made some inroads, "no type of treatment (has) showed clear superiority" (Hartmann, Herzog, & Drinkmann, 1992, p. 159). In fact, in a meta-analysis conducted by Hartmann et. al., results showed, "no significant differences between the 'absence' or 'presence' of group setting, cognitive, behavioral, educational, humanistic or psychodynamic techniques or relationship, symptom or conflict-orientation, was found" (p. 163). Hartmann et. al. discovered that "cognitive and behavioral techniques were described in practically all studies" (p. 162) and that within those studies, "the extent and way in which the applied interventions were described varies tremendously" (p. 164). They summarized by recommending careful and extensive descriptions of what, and how, treatment is being done suggesting that "explicitly helping to see and (emotionally) understand the connections between symptom behaviors and relationships seems to significantly improve the effect of the therapy" (p. 165). 12 Use of Imagery This study aimed to afford an opportunity for more careful and extensive descriptions through the use of both art therapy and guided imagery. Art therapy has been applied to myriad psychological problems (i.e., post traumatic stress disorder, Berkowitz, 1990; masochism, Campbell, 1990; multiple personalities, Frye, 1990). Little work has been done with regard to utilizing art therapy to treat bulimics. Macks (1990) and Amari (1986) have both conducted fairly successful research employing clay as a healing medium for eating disorder clients. An extensive search rendered three pieces of research (Conn, 1991; Naitove, 1986; Wooley & Kearney-Cooke, 1986) citing the use of drawing in the treatment of bulimia. Conn used art therapy to effectively access feelings and underlying issues with two hospitalized bulimic women. Naitove found that treatment was initially successful but was prematurely ended. Wooley and Kearney-Cooke developed the Colour-a-Person test wherein patients were asked to colour in the outline drawing of a female body as a form of self-assessment that began the process of body-image therapy. However the test was employed more as an assessment tool than as a therapy tool. An increasing number of articles have been written about guided imagery (i.e., wound healing, Holden-Lund, 1988; early memories, Edwards, 1990; depression, Gehr, 1989). Richardson (1982) has described imagery as "the ability to generate images, mental pictures of people, objects and things which are not immediately available to the senses, and then to reshape these into new and complex forms". Guided imagery is believed to facilitate the generation of those images and mental pictures which have the inherent capacity to arouse or uncover intense affective reaction and to enable deep emotional exploration (Horowitz, 1970; Sheehan, 1972; Singer, 1979). The process affords access to similar areas of awareness that can be found in dreams while a person is conscious (Achterberg, 1985; Progoff, 1963). The potential role of guided imagery in brief therapy has been examined by Feinberg-Moss and Oatley (1990) who discovered no significant differences between 13 imagery and non-imagery treatment groups. However, imagery therapy was found to be significantly better than an attention-only control group. They also conducted a follow-up session, and asked clients to complete questionnaires on Likert-type scales regarding both satisfaction with treatment and therapist characteristics. Clients in the imagery group provided higher ratings on both dimensions. Several studies skirt the concept of treating bulimics with guided imagery through addressing some of the issues with which bulimics wrestle. Rojcewicz (1990), for example, used guided imagery to enable a client to move from an absence of feelings to being able to experience emotions. After five months of therapy, the client was able to summon the sensation of his whole body expanding. Zulkosky (1991) reported a rich set of commonalties among five women in her exploration of the 'wise woman' as a therapeutic tool in guided imagery as a process of personal change. The effect of a treatment based on the use of guided visuo-kinesthetic imagery on the alternation of negative body-cathexis in women has been examined (Sankowsky, 1982) resulting in measurable improvements in both body and self-cathexis. An audio-taped imagery program has been employed as a primary stimulus to investigate the perceived control and coping self-efficacy of female bulimics (Howe-Murphy, 1987). And the use of imagery and journal writing (Farr, 1990) was found to allow clients to effectively discover and explore emotions related to important life issues and events. Finally, Miller (1991) focussed on people with body-image disturbances. She suggested the use of imagery, along with the suggestion of mirror work and the use of collages and photographs, and drawing as possible treatment methods. However, she did not discuss the results of treatment. It appears that only one study has directly explored treating bulimics with guided imagery. Hill (1992) documented the successful use of fairy tales as a safe vehicle by which to bypass defense mechanisms and access underlying issues. Clients were encouraged to identify with fairy tale figures and create action metaphors by working on resolutions for the characters' problems which they could then adopt in dealing with their own issues. 14 Outcomes included the enabling of clients to experience "self-love not yet owned" (p. 586), that is, discovering that their beings are worth defending. Phenomenological Studies Several studies have explored the bulimic world from a phenomenological perspective. Most of the research is very recent and in the form of doctoral dissertations. There have been a number of salient findings. Swirsky (1991) felt that bulimics used the binge/purge cycle defensively. She also found bulimics to have difficulty with interpersonal relationships, excessive self-criticism, and coping under stress. Tennessen (1991) discovered bulimic women were less satisfied with their achievements and held less realistic expectations. Grissett (1991) reported that bulimics feel less socially competent in a variety of situations and were rated as less socially effective by observers unaware of their group membership. The global self-concept of bulimic women appears to be significantly lower and negative emotional response and deprecatory self-appraisal significantly higher than in non-bulimic women (Tryniecki, 1991). Further, bulimic women seem to be more likely to be involved in dependent, enmeshed intimate relationships; are significantly more dependent than control subjects; experience significantly more loneliness; and express more dissatisfaction with levels of social support received (Kramer, 1991). Worth (1989) found the issue of separation and the creation of an autonomous sense of self to be a pivotal concern. Printz (1989) suggests that bulimics perceive that they are not living up to the expectations of their parents. She also found that bulimic women did not identify with the traditional feminine role. Jones (1989) discovered six themes in the bulimic experience. The first, the social process of bulimics included (a) control of self by self, (b) control of environment by self, (c) control of self by other(s), and (d) control of others by self. The other five themes were ideal or perfect child, feelings of rejection, feelings of anger, deviant sick role, and the need for secrecy. Herrington (1991) suggests the issue of control is common to all bulimics and 15 that it is played out as the struggle between having and not having control over self, food, and world. She reports the cycle as one of turning away from an anxiety-creating and overwhelming world to the isolation of food. She describes bulimics as simply overpowered by their desire, often experienced as an alien force, to surrender to a binge. The binge usually brings temporary feelings of comfort and control as well as a reprieve from their usual experience of self. If purging ensues after the binge, it functions to both prevent weight gain and to regain a feeling of control. Herrington describes the bulimic's sense of loss of control as extending beyond food to their sense of agency, and, often, even their sense of self. Patton (1992) found fear of abandonment by significant others underlying disturbed eating behavior. She cites that 67% of bulimics recall a significant event involving the loss of, or separation from, an important relationship prior to the onset of their bulimia. Patton suggests that binge eating may be "one method bulimics use to alleviate fear of abandonment and to symbolize merger with the maternal object when unconscious fears are stimulated" (p. 484). Igoin-Apfelbaum (1985) discussed bulimic patients' symbiotic feelings for their mothers. He described them as both avoiding and being drawn to their mothers while "the main feeling was that of shared inescapable distress" (p. 164). Women with eating disorders have been cited as experiencing more global shame and guilt as compared to normal women and they experience more shame and guilt in relation to eating compared to both normal or depressed women (Frank, 1989). Reynolds (1991) found a significant relationship between the severity of the eating disorder and the degree of internalized shame. His results supported several phenomenological experiences reported by bulimics through the literature: the presence of feelings of inadequacy, being hypercritical towards self, a wish to hide and avoid others, intense fears of abandonment, a wish to be somebody else, and feelings of contamination and self-disgust. Reynolds also identified several phenomena interpreted as defenses against shame including perfectionism, envy, and struggles for power and control. 16 A number of phenomenological themes emerged from Neufeld's (1983) case studies: abandonment by the father, need for protection and fear of failure, fear of rejection, preoccupation with body size and shape, fear of separation, fear of aloneness, being-for-others, fear of and deep sense of guilt, sense of obliviousness and depersonalization of self, need to purify, feeling like a sex object, fear of fear of relationships, feelings of worthlessness and, invalidation of perceptions. Finally, Hsu (1990) explored the cycle of the binge. He suggests that most bulimic women prefer to be alone when they binge and that negative feelings are common before a binge, especially those of depression, anxiety, and boredom. He also found that eating virtually anything is a "powerful precipitant of a binge for most bulimics" (p. 51). Hsu charted feelings throughout the binge/vomit cycle and discovered that dysphoric pre and early binge feelings give way to feelings of "exhaustion and dirtiness" (p. 54) followed by general relief after vomiting occurred. However, a gamut of feelings such as "guilt, anger, emptiness, happiness, and oblivion" (p. 54) often coursed through the bulimic during the entire episode. Hsu discovered that the most common self-statement made during the early part of the binge was, "Now that I have done it, I might as well go all the way" (p. 58), followed by statements filled with self-condemnation, bewilderment over loss of control, and giving up. Overall summary of the Literature Review 1. Bulimia is a major health problem which is growing exponentially. 2. No clear consensus has been reached regarding a critical point when eating behavior becomes pathological. 3. No primary cause of bulimia has yet been determined. 4. No comprehensive treatment has yet been determined. 5. More research needs to be conducting into the essence of the bulimic experience in order to work toward answers for the above concerns. 17 III. Method Design This study was implemented utilizing a multiple case study design. The multiple case study format offered a strong base from which to cite discoveries. As Yin (1989) states, "if two or more cases are shown to support the same theory, replication may be claimed" (p. 38). Yin continues to expand on the usefulness of the case study approach in general by suggesting that case studies afford an opportunity to explain connections between complex interventions which function beyond the realm of experiments. Woodman (1982) argued that bulimics are not consciously aware of their problems or the depth of issues that are involved. For the purposes of this study, gaining access to deeper realms of the bulimic mind necessitated the use of more intuitive methods, such as art and fantasy. Many studies have employed questionnaires or interviews to explore the bulimic experience (Cooper & Fairburn, 1992; Hsu, 1990; Hsu & & Sobkiewicz, 1991; Keck, Pope, Hudson, McElroy, Yurgelun-Todd, & Hundert, 1990) limiting information to what could be explicitly stated. This study sought to uncover implicit information utilizing not only in-depth discussion but imagery as well. The use of imagery was intended to access tacit personal knowledge. The goal was to facilitate the creation of concrete visual images: in the mind's eye and on paper. Imagery provided a vehicle by which the women in this study could explore their relatively inaccessible inner landscapes. Guidano and Liotti (1983) suggest that the "relationship with self-knowledge can be only of an indirect type; that is, individuals use mainly inferential procedures in order to construct those characteristics they consider to be their distinctive features" (p. 59). They state that the relationship between tacit and explicit self- knowledge is "based on a continuous interplay between the individual's intentionality, regulated by conscious knowledge about oneself, and the aspects of his or her imaginative 18 and emotional life, which are mainly regulated by tacit self-knowledge" (p. 60). In light of Guidano and Liotti's observations, the benefit of attempting to fathom implicit personal knowledge, identifying fragments of thoughts and emotions, and bringing them to conscious awareness may be of particular relevance in the study of bulimia. Perhaps the lack of previous exploration of the tacit self in bulimic individuals may partially explain why bulimia is still so poorly understood. The exploration of the tacit self in this study was introduced within the framework of a treatment program which attempted to promote change. Attempting to promote change was viewed as an essential component of the study. In considering the accessing of the tacit self, Guidano and Liotti (1983) note, "the material sometimes represents an important demand for change in personal identity, since the imaginal stream tends to circumvent the individual's attempts to maintain specific beliefs on self and reality through selective exclusion of incompatible stored or actual information" (p. 77). Arkowitz (1989) suggests that behavior change can be used as a source of insight. According to Bronfenbrenner (1979), much can be learned through observing the process of "transforming experiments in the real world" (p. 40). Based on the above perceptions of change as a tool by which to gain further understanding, a treatment program, rather than a series of interviews, was employed for this study. To determine the feasibility of a treatment program which would yield rich information, two pilot studies were conducted employing both guided imagery and art. The two, self-selected, bulimic clients, a 24 year old female and a 53 year old male, each received four, one-hour-long sessions. The pilot study resulted in both clients reporting the discovery of useful insights into their eating patterns, and very positive changes in both their bulimic behavior and their attitudes toward their body images. Both expressed a strong desire to continue treatment. 19 Participants Three self-selected, bulimic women solicited from the self-help group, Overeaters Anonymous (OA), participated. The clients ranged in age from 23 to 35 years old. Clients responded to a personal request on the part of the student researcher at OA meetings. All participants completed a brief screening questionnaire (Appendix A) based on the DSM- IIIR criteria for bulimia (maximum total score =35), and a consent form (Appendix B). Only clients with a score of 28 or more (scored an average of greater than three out of five on each question) were accepted. Clients were also screened for their ability to articulate their experiences and for their availability. Cynthia background. Cynthia was a slim, 23 year old woman. She had a younger sister. Her parents were divorced. She was sexually abused by both her parents when she was a child. During her teens, she was heavily involved in drugs, alcohol, and some street activity. At the time of this study, she was estranged from all of her family members. Cynthia became bulimic 11 years ago at age 12 when a friend showed her how to throw up. By the age of 15, she was binging and purging up to 20 times a day. When we began our sessions, Cynthia was purging once or twice a day. Cynthia had seen several psychologists, psychiatrists, and counsellors over the years for a variety of issues. She did not find them exceedingly helpful. Sonya background. Sonya was a slim, 35 year old. She had a younger brother and an older sister. Her father left the family when she was two weeks old. She was raised by her mom who was at times single, and at times married. Her mother's various husbands functioned as step-fathers. When she was 12 she was sexually abused by one of the step- fathers. As an adult, Sonya had been in several abusive relationships. Currently, she did not drink, smoke, or take drugs. She was agoraphobic. She had been bulimic for 22 years, 20 since she was 13. Sonya had binged and purged over the years to the point of damaging her esophagus. For that reason, she had had to curtail her purging to "spitting" out food after masticating but before swallowing. She did this many times a day. Sonya had seen many psychiatrists, psychologists, and counsellors over the years. Alison background. Alison was a slim, 33 year old woman. She had an older brother who lived in Alberta. Her parents were retired on Vancouver Island. At the time of our work together, She was experiencing her first long-term, live-in, relationship with a man named, Jordy. Alison became an alcoholic at age 12. She quit drinking two years ago and had stayed sober. She quit smoking three months ago. She had never really done drugs. Her parents never knew that she drank or smoked. Nor had Alison ever told them about her eating disorder. She began binging fifteen years ago at age 18. At the outset of treatment, Alison was binging and purging on a regular basis. She binged regardless of whether she was happy or sad. Usually, she would binge for about five days straight and then purge it all out. Alison had never seen a counsellor prior to our work together. Counselling Program All treatment took place at the U.B.C. Counseling Psychology building. The theoretical framework within which the treatment program occurred was one of humanism. Specifically, client-centered therapy was employed as a caring and supportive method by which to conduct in-depth discussions and information-gathering within a primary framework of unconditional positive regard. Secondarily, an eclectic assortment of therapeutic paradigms were introduced throughout the course of treatment to encourage and support positive change. For example, Gestalt role-playing was employed in an effort to rehearse for difficult or frightening situations; rational-emotive therapy was utilized in an effort to amplify and explore irrational thought processes; and cognitive-behavioral 21. relaxation techniques were used in order to provide an opportunity for participants to experience some inner peace. Art therapy and guided imagery techniques were introduced as complementary processes by which to further facilitate the expressive abilities of the client. The use of drawings began at the outset of the first treatment session with a warm-up technique (Naitove, 1986) of three drawings. The drawings were titled, numbered and then discussed briefly. The whole exercise was designed to free clients from concerns about their lack of skill and/or talent and/or aesthetics when creating artwork in front of a therapist. The Three Selves Test (TST) was then be administered (as it was again during the last session). Other drawings were encouraged throughout the sessions as they naturally evolved out of discussion, i.e., a subject might mention a feeling of tension at the family dinner table at which point the therapist might ask the subject to draw a picture of that tension. No set number of drawings was required. The use of guided imagery was employed whenever it appeared warranted as dictated by the flow of the conversation and/or the flow of the drawings being created, i.e., a subject may feel blocked about certain emotions surrounding food and her mother. The therapist may then suggest conducting some guided imagery work around that block. The guided imagery method employed was a very straight forward technique based on Miller (1991) wherein the therapist asked the client to relax, close her eyes, and go to the place in her body from whence the tensions or feelings regarding a particular issue seemed to be emanating. The client then reported the images that she 'saw' and a conversation regarding that phenomenological experience ensued. In an effort to respond to client needs, no set number of guided imagery exercises per session was required. Finally, openness to client experience on the part of the therapist was earnestly attempted in order to achieve depth, richness, and insights into the client's world. To that end, the therapist attempted to adopt what Arnold Mindell (1985) describes as the fluid 22 ego wherein one is open to "the body experience, mood, or fantasy" (p. 65). A client's fleeting glances, brief pauses, shifting body movements, and the like, were responded to by the therapist with the use of immediacy to facilitate deeper elaborations. In this spirit, the therapist attempted to adopt the role of what Mindell describes as the "process scientist. He is able to both participate and hold his distance from events. He identifies himself with his primary processes in time and space, and also with the stream of events, those secondary perceptions. He maintains his normal sober intellectual consciousness while simultaneously participating in processes" (p. 66). Sources of Information Data were collected through a participant-observation multiple case study format employing: audiotapes and transcriptions, imagery, a therapist's log, reflective discussion, opportunistic sources of evidence, and weekly telephone conversations. Audiotapes and transcriptions. The audiotapes and transcriptions served as a core data collection strategy. Audiotapes of each session were transcribed immediately following each session. Imagery. The use of imagery as a data collection strategy constituted an entirely different language, requiring different "words" and forms of expression. The drawings and symbols created through the use of art therapy and guided imagery exercises provided a very different perspective through which to process the bulimic experience. Ideally, encouraging the bulimic to speak in a relatively new and different "language" would spark the release of undiscovered information from their psyche which could then be translated into speech and conscious thought. The TST was used to contrast any changes which occurred in the nature of the three drawings representing various methods of body-perception. The TST was based, loosely, along the lines of the House-Tree-Person test (Buck, 1948). Buck asked clients to draw a house, a tree, and a person and attempted to glean information about the client based on 23 the way those items were rendered. Clearly, the TST was a novel and largely unvalidated measurement and treatment tool. Therapist's log. The therapist's journal served as a subjective participant investigator record of observations not apparent in the session transcriptions. Unspoken actions, the ambiance in the room during the sessions, and client energy levels were all recorded in the therapist's log immediately following each session. The therapist's log was written based on recommendations by Van Manen (1990) to attempt to describe the experience of the session "from the inside, as it were; almost like a state of mind: the feelings, the mood, the emotions" (p. 64). Reflective discussions. The reflective discussions were conducted in person and on the telephone between the thesis supervisor and the researcher on several occasions throughout the course of data collection. The discussions served as an objective landscape in which to document cycles of transformation and to reflect on the potential implications of session developments. Questions were posed about the treatment sessions, doubts were expressed, hypotheses were shaped and reshaped, and new approaches to roadblocks or weak links in gleaning the essence of the bulimic experience were formulated. For the reflective discussions work, a different mindset was required on the part of the researcher. As Mindell (1985) describes one needs to become, "a chronological observer...like a classical physicist.. .holding his distance from events" (p. 66). Opportunistic sources of evidence.  Opportunistic sources of evidence provided a method by which additional material could be acknowledged and processed. This category provided the opportunity for evidence such as photographs, dreams, and significant people in the lives of the participants to be incorporated into data collection. Telephone debriefings. Finally, the weekly telephone conversations afforded clients the opportunity for further reflection regarding the content, and ramifications of thoughts and emotions explored in the sessions. It was hoped that both the physical and the 24 chronological distance from the sessions would provide the ability for a different perspective to be experienced and expressed by the clients. Procedures Prior to treatment, participants engaged in an hour-long case history pre-interview. Treatment occurred over a six week period. Two hour-long sessions were held each week. At the end of each week, the therapist telephoned each of the clients to discuss their reflections on the week's work and any additional insights they may have had into their behavior. Approximately six weeks after the final sessions, clients were asked to offer their comments, feelings, and reflections experienced in the aftermath of the study in an hour- long interview. This session provided an opportunity to defuse any possible negative consequences of, or field any positive comments about, having participated in the study. Analysis Materials gathered over the course of the sessions were processed systematically and exhaustively with two focuses in mind: identifying aspects of construing and experiencing, and discovering patterns of experience. These two focuses became the "descriptive framework" (Yin, 1989, p. 107) by which to fathom and analyze case studies material for insights and content linkages. Overall synthesis and analysis of the data embraced Van Manen's (1990) approach whereby many levels of assessing a phenomenon were incorporated. To begin, each woman's 12-session account of her bulimic experience was intimately reflected upon as a whole. Next the accounts were reappraised such that significant units of meaning relating to each woman's bulimic experience were extracted; transient, irrelevant material was culled out. The sessions were reviewed again, this time, in an effort to reduce redundancy, to begin to cluster the units of meaning, and to begin seeking out patterns of 25 transformation. Preliminary clustering of themes emerged from dozens of phases pulled from the transcripts which had the potential for units of meaning. Most phases were culled out. The high repetition phases were then reflected upon as possible themes. Once the different themes had been formulated, the original transcripts were revisited in an effort to guard against the possibility of distortion of the data. This process was followed by a lining up of units of meaning, or themes, across the individual case studies. Finally, the commonalty of the meaning of the bulimic pattern of experience was sought across the women's cases. Each source of evidence provided a unique contribution to the descriptive framework. Transcriptions of audiotaped sessions, opportunistic sources of evidence, and telephone conversations were employed to create detailed accounts of the clients' subjective, explicit worlds. Session summaries presented in the case studies chapter are the result of careful, thoughtful distillation of the most salient units of meaning which became apparent in the sessions. Yin (1989) defines an "embedded unit of analysis (unit of meaning or theme) as.. .a lesser unit than the case itself, for which numerous data points have been collected" (p. 121). Depending upon whether or not conversations within each session were perceived to be pivotal links in the chain of themes being forged, entire sections or only quick synopses were related. For example, consider 'a sense of Godlessness' as a unit of meaning. Whenever any of the participants chose to elaborate on their feelings shedding light on the nature of that specific theme, the complete documentation of the conversation was left intact so as to provide a clear, uncut picture. Further, choice of words, pregnant pauses, sighs, verbal idiosyncrasies, and the like, were faithfully charted in an effort to build a rich and deep context of individual experience for each bulimic woman. Following documentation of each woman's own experiences, the therapist's logs were incorporated into analysis as secondary sources of information. The therapist's 26 subjective experiences of the sessions functioned as a method by which to make implicit information, such as a client's general energy level during a session, more explicit. The greatest opportunity for the eliciting of tacit material came through guided imagery exercises and drawings. The analysis of this information was extremely challenging. Guidano and Liotti (1983) caution that although tacit self-knowledge is irrefutable, this is not knowledge that can be simply stored in the mind and summoned up at will. They suggest that images are reconstructed each time they are called upon, and that "imagining is an active mode of information processing, which makes the elaboration of each image a unique construction" (p. 75-76). With this in mind, it is probable that each image generated by the women was imbued with many layers of meaning some of which were charted and some of which remained undiscovered. The nature and the meanings of guided imagery exercises and the drawings were, first and foremost, considered in concert with the clients during sessions. Their perceptions of the symbols they generated were recorded and reflected upon. In addition, all drawings, including the TSTs were analyzed by means of qualitative ratings of individual drawings (Allan and Clark, 1983). Elements such as the amount of time the client spent on one aspect of the drawing, how they focused on one particular symbolic component and so on were carefully observed, recorded, and considered. All of the sources of evidence contributed to pattern-matching, initially throughout the individual cases in a effort to identify themes (within cases), then between cases studies (across cases) demonstrating what Yin (1989) describes as "literal replication" (p. 110). Threats to the validity of the findings were also addressed. In an effort to strengthen this study's internal validity, analytic tactics such as pattern-matching and explanation-building were adopted during data analysis (Yin, 1989). Further, Yin suggests that another method to minimize researcher bias is to "report preliminary findings while still in the data collection phase" (p. 65). Yin reasons that immediate reporting may help to minimize inadvertent skewing of data processed long 27 after collection. This method was also incorporated into the data collection and analysis through immediate (within 24 hours) transcription following sessions. Hopefully, the employment of that technique helped to alleviate the temptation to avoid, or bury, contrary findings through committing them to paper prior to the formulation of overall results. This system also maintained a chain of evidence of both the session conversations and the investigators phenomenological reactions to each session such that an external observer could clearly follow the data collection process. Information was presented and analyzed in chronological order for the purposes of clarity. Chronological analysis allowed for the clearest possible vision of participants' overall patterns of transformation through the course of session work. Yin (1989) suggests that "the ability to trace changes over time is a major strength of case studies" (p. 116). The use of pattern-matching over time, between and within each of the case studies, allowed for an overall pattern of experience to emerge. On a final note, the analysis of case studies is not yet an exact science. As Yin (1989) has noted, there is still a "need to develop more precise techniques" (p. 113). To that end, it is virtually impossible to be sure that a completely thorough analysis of the data was undertaken. However, every effort was made to draw from a number of sources of evidence, to guard against distortion of information by checking and rechecking the evidence from which the descriptive framework was developed, and to be mindful of roadmaps and caveats described by previous researchers. 28 IV. CASE STUDIES This chapter will present thorough summaries of the counsellor's entire relationship with each of the three participants. The cases are laid out sequentially, in chronological order. A therapist's log, complete with observations about some guided imagery exercises and the drawings, appears after each session. At the end of each week of sessions, a summary of one or more telephone conversations appears. Opportunistic sources of evidence are included in the body of the session summaries. Cynthia Session 1, November 2. Cynthia arrived chewing gum and drinking a fruit juice. She immediately asked about changing her session time. She had already switched her pre- interview time. As we began the warm up drawings, Cynthia talked about having participated in some art therapy once before. She found it to be very threatening in that it had raised a lot of deep issues around her childhood sexual abuse. She talked about a previous counsellor with whom she had worked. Cynthia said the counsellor was "obese and had no control" so she didn't like her or have any respect for her. Cynthia also talked about the terrifying fear she experienced around anyone who was obese in that "fat might be something that is contagious. And that, they are so out of control. They let themselves be like that. And then I feel sorry for them because I think they must feel so awful about themselves and stuff. And it must be such a great shield to be that...fat. Like the whole world would be just.. .it's a great way to keep the world out. I mean, even though they are fat people, most people are not nice to them. And I am sure they are nice people. Like once you talk to them. But the way I push people away, a lot of times can be so hurtful. Like I am so venomous, like they will never forgive me, you know what I mean?" I asked for an example of how Cynthia pushed people away and she cited middle- aged men. In particular, she had recently experienced what she described as a very 29 demeaning interview with a middle-aged lawyer. She ostensibly refused to talk with middle-aged men because they made her feel powerless and she feared them. We stopped briefly to title and explore the warm up drawings. Cynthia entitled the first drawing (Figure C1.1), "Kite", the second drawing (Figure C1.2), "The Coffin", and the third drawing (Figure C1.3), "Living Room". She reacted, "Um, the kite, I don't know why, I just drew it. And this is a coffin. That's a door, but it's kind of like a coffin". Cynthia pondered the significance of the coffin image and said very softly, "this is maybe like dead feelings or deadness". She laughed nervously, "there's a person inside of it." Regarding the living room picture, she offered, "everyone is sitting in their spot. And there's four people. There's four people in my family. And everyone has their assigned place. Then it looks like a nose. Two eyes and a nose. It just kind of looks like a person's head. Everyone has to be a certain way.. .well you never really knew what way you had to be. But, you knew it had to be someway, even though you didn't know exactly what way you had to be", she laughed uncomfortably. We began the TST drawings with "How the world sees me" (Figure C1.4). Cynthia talked as she drew, "there is a significant thing to it because I always see this part as being okay. Up to about here (she points to the head and shoulders of the figure) like above the breasts, from here up is okay. But from down here, it looks to me like, quite, big. It's quite large, it's like a not very proportioned person. I always think people think I am a totally neurotic, totally like freaking out, like confused energy. I used to think that my boobs were like this big", she exclaimed dramatically, making a large gesture. "Like I had to get them cut off but I don't really feel that way anymore. Only if I look at myself in the mirror, naked... distortion. Sometimes it's scary when I look in the mirror. Sometimes I see my body the way it is. Sometimes I see it thinner than the way it is." As Cynthia completed the second TST drawing (Figure C1.5), "What I see when I look in the mirror", I asked her about the patches of colour. She explained, "they are all 30 feelings Like when I look into the mirror sometimes I see real distorted images that aren't true and I know they are not sometimes I think I am crazy. I look into the mirror and know they are not. It is impossible to have breasts that are like that. It is impossible to have scars on your body that are like that. You know what I mean? Like it's not.. .1 think, 'oh God, you are going crazy'. Yeah. I think that it's like my mind has gone crazy. Sometimes I look in the mirror and I totally feel like all I can see is black. And other times I just see a person.. .like hollow. And other times I just see a person getting dressed.. .usually I where black. Like I don't really use a mirror that much. I don't always trust what I am seeing. I know that sometimes what I think I see isn't really what's real because I have become distorted in my views." In response to the final TST drawing (Figure C1.6), "My Inner Healer", Cynthia mused, "I am a very colourful person. I never thought about wise anything before.. .but I always think about it as a light. I little tiny light that grows and grows and grows but it is always there, I can't get it out no matter how hard you try and the bad things you do." At this point, Cynthia agreed to a guided imagery exercise wherein she visualized the little light inside which she described as "a lining." I asked the little light about the significance of her harrowing conversation with the middle-aged male lawyer. She answered glibly, "the light says it doesn't really matter. He is just something that passed through my life that gave me an opportunity to learn something." The voice of the light continued, "just do what you have to do to take care of yourself. Go work out. Eat normally. Have friends. Phone people up. Be more social. Have more fun. Just go have fun. Just forget about it." I asked the light about Cynthia's attitude toward men. She responded, quite assertively, "it's good because it protects me. A lot of men are not good. Well, it's not that they are not good. They are just not safe. They are quite bad." I probed further and she conceded that In fact, men "are just people. They are not anything special. They are not better than you or worse. Just people." 3 1 After we completed the imagery exercise, Cynthia reflected that, "it's my responsibility to take care of myself and I can't give anyone else the responsibility to take care of me because then I will get hurt." I queried if this feeling extended to women as well, she reflected, "well with women a lot of times they don't have this overpowering need to hurt people. Like they don't...their vendettas against life are usually more directed against themselves than others". Therapist's log, session 1. I was struck by Cynthia's vibrancy and her physical beauty. Further, I was intrigued by two actions which may have been a manifestation of passive/aggressive behavior: the juice drinking and the gum chewing, along with a need to slightly change session times, felt like a ploy to establish some control. I had the impression that the food was being used as a way to create a safe distance between the two of us. The time changes felt like some kind of test regarding my willingness to bend to her needs. I did so. I wanted to provide her with feelings of as much support as possible. Cynthia's mannerisms were quick and somewhat flirtatious. She played with her hair constantly and moved around in her chair a fair amount. She spoke at a furious pace with ample amounts of humor, self-deprecating and otherwise. At times, I felt myself feeling like I was at a pajama party listening to secrets out of school. Simultaneously, I felt as though I was being carefully sized up and scrutinized as to my trustworthiness. I detected a touch of envy in her diatribe about her fear of fat people. It was almost as though being fat would, in some ways, be a welcome relief in that she could finally eschew others' expectations of her beauty. With regard to her fear of middle-aged men. I found myself strongly suspecting a direct correlation between her father's sexual abuse of her when she was a child resulting in a feeling of powerlessness and her current experiences. Her contempt of men was so strong it was almost palatable. 32 Figure C1.1. "Kite": The use of the orange and red suggest the presence of creativity and sexual energy. The image of the kite suggests both a desire to fly away and yet control, with a string, the nature of the flight. The flowers at the bottom of the page appeared wilted or squashed somehow, unable to fully bloom. Figure C1.2. "The Coffin": The combination of the colours blue and brown may point to some statement about men and excrement. Interestingly, although the coffin may symbolize death, it is not quite closed, suggesting hope for life. Cynthia also described the coffin as a kind of door. Woodman (1982) discusses the significance of the coffin imagery in bulimics in some detail speculating that a coffin may be expressing a bulimic woman's feelings of "standing outside looking in, yearning for what other people take for granted.. .In her aloneness, she fantasizes her emotions, but she has no "I" with which to experience real feeling. Life does not flow through her" (p. 135). The black flower image may suggest something that was alive and beautiful but is now dead, or in a death cycle. Figure C1.3. "The living room": The box shapes may point to a need for symmetry; a lack of feeling of creativity or freeness in the family environment. Figure C1.4. "How the world sees me": Although Cynthia said she felt that she was "alright" from the shoulders up. She has not detailed her self-portrait with a nose or a mouth. She has, however, made her eyes purple, which suggests a kind of spiritual presence. Cynthia also did not depict hands, or feet, or a groundline suggesting a lack of connection to the world. Figure C1.5. "What I see when I look in the mirror": Of particular note, the purple (spiritual) line Cynthia has drawn to divide herself from her emotions. Figure C1.6. "My Inner Healer": This multicoloured pyramid filled much of the page and was intended to depict the "little white light". Cynthia was able to draw this image immediately and confidently. 33 Session 2, November 5. Cynthia began by expressing anger at her boyfriend who went to a concert without her. She said she felt rejected and abandoned. She also related a dream she had that morning wherein she was different from everyone else and completely alone which made her feel filled with "total despair." Cynthia broke down and cried as she explained, "I have always felt this way. I always pick people that can not be counted on that are not dependable, that are not reliable, they are not. They are there one day but they are gone the next and I have been trying to figure this out in the last couple of days. I have always felt, like different from everybody else. And like I don't want to.. .1 wanna fit in but I don't. When I am there, when I am fitting in, I don't want to be there, I want to break out. And then I can't get accepted." Cynthia stopped crying and began talking about an awareness of a paradox in her emotions toward her boyfriend in that she felt she could have sex with him but that she harbored a "huge resentment" toward him for going to the concert without her. She ascribed an irrationality to her thinking yet she felt "deeply wounded" by it. We began talking about the nature of abandonment; what it felt like, looked like. Cynthia drew a picture to explain, (Figure C2.1) "this is everybody all back here and this is me right here. And like there is no way, it's like a wall and I can't get through it no matter how hard I try and like this is me. And I sold myself out to these people my whole life. Like my, every single day of my life, that I have lived on this earth until I feel like today, right at this very moment. When I was taking the bus here, this feeling came over me like I just said, 'God, you are the only one that can help me. This is something spiritual. This is like a lack, right. There's no person. I am not asleep anymore it's like I can't explain this rationally because it isn't. And so I am on the bus and this feeling came over me like, 'fuck them'. YOU have so much potential to BE. To be totally and completely accepted. I have so much potential to achieve. That's how I thought like this thing. And you are totally missing the boat. These 34 people are not who you need in your life! Like all of 'em. Like throw them out. Find a group. Find a group of women. Get involved with women that are moving. Who are individuals. Who are fighters. Who are like ME!!! And, like, what am I doing with these, these followers? I feel like a piece of shit. I am always hitting the same wall my whole life. I have been around average people who only see one way, one tunnel and that's the way they are. But that's every person in my life today. Those are all the people that I am trying to get my validation from." Cynthia then told a story of a big fight she had had that day with a female school counsellor who had made, what Cynthia deemed to be, some insensitive remarks regarding sexual abuse. In telling the story, Cynthia cursed and swore and expressed great delight in having blown off a lot of steam in the classroom in front of fellow students. I listened and then suggested her strong feelings may have centered around a fear of abandonment. She agreed and added that she often felt abandoned. She shored up her belief with an example of how she was shunned last year at a drug treatment center she had attended. She also pointed to the lack of support she felt in her family from the age of eleven on. We then took time to explore if Cynthia had felt any support in the classroom during and after the fight. Cynthia acquiesced that two women did come forth and voice their support of her. She then added the two women at her side in the drawing of her alone against the world (Figure C2.1). We examined the difference between reality and her immediate sense of reality. She questioned herself, "why do I see it as I am completely alone?! I felt so sorry for myself. I cried, and nobody likes me. Why is it so important? How do I accept people for who they are? How do I do that? Where do I go to get my needs met?" Cynthia drew a drawing responding to those questions called, "The Path" (Figure C2.2). We moved on to discuss whether or not Cynthia accepted herself for who she was. She felt she unequivocally did not. We also explored how Cynthia seemed to lash out in a selective way; how she got mad at other women but chose not to show her considerable 35 anger to middle-aged men. Finally, we explored how her eating behavior may relate to her erratic ability to express herself. Cynthia reflected, "Yeah. Like I take it out by eating or doing whatever. Or throwing up. Like with that man. I mean that is my eating disorder. That is what I feel is my eating disorder right there looking at me right in the eye. It's like the inability to assert myself in a way that will best suit me and bring out the best in me." I suggested softly that, "when you were sexually abused by your parents. You were unable to assert yourself." She replied, with an incredulous tone in her voice, "You know what I remembered the other day? When I was 8 or 9, I used to be in this Indian Princesses, from the YMCA. And it's like a group of men and their daughters. And I remember one day, there were about ten fathers and daughters and we all went back to their one man's home. And I said to the whole group of men something like, 'aren't we all going to get down and get to it'. Everyone looked at my father gave me a look like (demonstrates a scathing look) and I said it again! We left right away. My father punished me. Calling me names, calling me a piece of shit. I told his secret to ten men! And I said it right out loud. It's like when I look at men, I see them as people with no face. It's like they don't have a face. They have no brain. Men are like dinosaurs, they have two brains, one in their penis, like one in their tail and one in their head. And they are very, very small and they don't really amount to much. They don't really mean anything, they are just there to let them blink, or move, or be aggressive. Otherwise that can't really put two thoughts together that mean anything. That is basically how I grew up feeling. And in some way, some times, not for all men, but for the majority of men that I don't know, that's how I feel about them." I challenged Cynthia, "And yet, you told me in great detail, and with a great amount of anxiety, about the frustration you felt and the powerlessness you felt sitting in front of this, this lawyer, a man...with a gender for which you don't have any respect. So I am confused." Cynthia stuttered, "I...I.. know but I don't understand why. Like I don't feel better than them." 36 We took some time to talk about Cynthia's childhood. She felt it was a very unsafe place. She did not trust men. She did not trust women. She did not trust herself. Cynthia acknowledged, "No. I could never depend on anything or anyone. I was always wondering what was going to happen next. I was always scared to death that I was going to say the wrong thing or do the wrong thing or be the wrong person so when I could get away with something I would completely just go for it because I knew that I was going to get it anyway. And that is the way I have lived my life. Pushing everything and everyone to the extreme limit and in the back of my mind, I am going to get it anyway. And, in a way, I wonder if today's scenario (with the school counsellor), I could feel that same feeling, like I am just going to push this woman because I know she is going to snap.. .like, 'fuck you, like I am going to push you and push you and push you until you own it. LIKE TELL ME YOU ARE WRONG! Tell me you made a mistake to my face...say you are sorry say it, say it. But she wouldn't say it so I just kept on going. And then I had to leave the room." I asked quietly, "What did you want to feel?" Cynthia responded immediately, "I wanted to feel heard. I just wanted to feel acknowledged. I was going out of control, and I knew that I was going out of control. I knew that I was completely losing it.. .1 knew that I was just pushing and pushing and the more she said, we have to move on.. .it was like no, I don't agree, I won't follow those rules." Cynthia paused and then added, "Yeah, and then I thought when I left there.. .1 can't even make a mistake.. .1 thought I can't even be myself, I can't even make a mistake.. .1 don't know why I thought that. I can't be myself. I can't make a mistake like getting mad at someone in class." I asked Cynthia about the pressing need to be perfect. She began to cry stating that she simply is not like "normal women". I look around and everyone else is doing just fine and I am the fucked up one. I am the one who is a freak. That's how I feel. Everyone else is over there and I am totally alone. I honestly feel like that.. .it's awful." Cynthia cried and laughed at herself simultaneously, "Total self-pity!!" 37 I then asked Cynthia to further define what a normal woman was. She did not do that instead, she began to describe her vision of what women, and, in turn, she, should be like, "I believe every woman has to like get out of the mold. Get out of what I have been taught. Move away. Take who I was and completely move myself out. I don't have to wear dresses. I don't have to look this way. I don't have to act this way. I don't have to stick my fingers down my throat to express myself. Like I shouldn't have to do that! I shouldn't have to smile when I don't want to. Or not cry when I wanna cry. Why should I be embarrassed? When I am angry why can't I yell? Why do I have to feel I am doing everything wrong?" Cynthia wept bitterly, "And I am looking at all these other people and they are supposed to help me but the only one that can help me is me. And I know that but I am still running over to those other people: please validate me, please tell me I am okay, please tell me." Cynthia moved on to talk about the inequities women experience in the workplace. She stated passionately, "I feel like because I am a woman that I am a victim. The minute I was born, I was a victim. If I had been a man, they probably wouldn't have touched me. They probably would have fucked me up but they wouldn't have touched me. They wouldn't have used me.. .the minute they found out, that's a girl, I am owned. A boy is a man of his own, but a woman has to be owned by somebody. I NEVER wanted that." Still in tears, Cynthia moved on to talk about transvestites. She wept as she described how they were shunned by everyone in society. And she spoke of how deeply moved she was by their commitment to being true to themselves against often overwhelming ridicule. "They are still dressing up as women, they are still proving a point. That really means something to me. They have so much guts. They just stand there and they look so horrible and so sick and so weird with their beards and they don't' know how to dress but they do it anyway because they believe that they are women, inside. You look at them and think, my God, they are freaks of nature. But on a spiritual level, it's like they are 38 the strongest fighters in the world. To me, I see something in them. Them will sacrifice opinion so them can feel like a woman. They are spit on and shunned, it AMAZES me!" I observed, "And it sounds as though, some days, you feel the opposite of those transvestites wherein you will do everything to please everyone in the world except yourself." She agreed without hesitation, "Yeah, yeah. That's like my path.. .1 would love everyone in the whole world just love me to death. I want everyone to love me but also..." Cynthia paused and asked me what I thought of her behavior. I told that I didn't have a view and that I hoped that by the end of the sessions she wouldn't care what my view was anyway. We then moved on to a guided imagery exercise exploring her sense of spirit. She stated that it felt like a breath. We pursued the breath which she described as a tightness in her upper chest. She felt that her chest was storing "poison infesting her from other people". She also began talking about how frightened she felt in that she was actually beginning to feel more emotions, "I FEEL SO MUCH. It just comes out like a big breath. Like an uncontrollable thing. It's almost like it is so awful and it wells up and wells up and it comes out and then I feel better for a couple of minutes and then it comes again. And I just feel so sorry for myself all the time. I am so sad. And I am all alone", she wept. She paused and added with a puzzled inflection in her voice, "I feel awful and I feel good." Therapist's log, session 2. I was struck by the unique combination in Cynthia of feeling sorry for herself, feeling like a freak, and being seemingly quite proud that she was different from others. Cynthia's world seemed so very black and white. It did not feel like there were any other colours in the middle of the spectrum. Also, I determined to continue to explore Cynthia's sense of spirituality through the transvestites whom she saw to be glorious martyrs pursing their truth against all societal odds. 39 Figure C2.1. "The Separation": The colour blue (masculine?) was prominent in this drawing. The wall she depicted appeared impervious. Contrarily, the people she eventual drew on her side were much smaller than she was, and looked quite ephemeral. Figure C2.2. "The Path": This drawing seemed quite joyful; filled with rainbow of colours suggesting both hope and the genesis of a sense of self. Telephone debriefing, week one. Cynthia said she felt embarrassed about her outbursts of emotion and anger in front of me because she felt she did not know me that well yet. She appreciated discovering that she had a lot of resentment toward women as well as toward men. She found herself thinking about how to help herself listen to others. She also delighted in the new sensation of trying to "reinforce the good stuff about me". She commented on feeling more willingness in general. Specifically, she decided to make an appointment to talk with her school counsellor about their communication problem. Session 3. November 9. Cynthia appeared to be in quite an energized mood today. She brought a cup of coffee which she sipped on during the first part of the session. And she asked to borrow a thesis, which she had noticed on the shelves in our therapy room, on transvestites. I arranged for her to be able to do this. She was pleased. Cynthia began by talking about her concerns regarding the expression of her feelings in the world. She was very worried that she would experience both fear and resentment if she did not feel heard. Cynthia was particularly concerned about whom, or what, to believe. She described, "The pattern is that, when somebody blames their behavior on me, I feel crazy. Because I am not sure if I am really.. .1 don't always know what to separate from their thing and my thing. Because I am never believing myself. Because I am never on my side and I am always looking for THEM to validate me. I am relying on what they think of me, not what I think of me. I have abandoned myself. Because I am looking at everybody else to tell me who I am. I say who I am. No wonder I have been walking around in a state of total fuckin' freakiness and my whole life of total frustration and 40 resentment and anger of the world. Because they are all misrepresenting me. They only see a part of me. It's ME that has to see who I am." I took a moment to reflect and amplify what Cynthia had just said. She responded, grinning, that she loved that she had the "guts to say it out loud". We moved on to discussing Cynthia's on going dilemma with her school counsellor. We determined that Cynthia had certain expectations of her counsellor because her counsellor was in a position of authority. I challenged Cynthia further that she was seeing something in the counsellor that represented a part of herself that she did not like. Cynthia responded that she felt the counsellor was "a total victim. My biggest resentment of her is no personal power...it frightens me to be in a room with people like that". We discussed the irony of the intimidating role Cynthia assumed in the class room in relation to her counsellor, which was somewhat like the intimidating role assumed by the middle-aged lawyer in relation to Cynthia. We explored the possible connection between a feeling of lack of personal power and wanting to binge and purge around those feelings. She became quite tearful around feeling guilty for having "embarrassed the counsellor and taking great joy in that. I feel so ashamed." We talked about how Cynthia could be kinder to the counsellor, and more forgiving of herself. Cynthia suggested one way of helping herself would be to define better boundaries. She came up with the idea of a big door with a screen in the middle of her forehead so that she could fully protect herself (Figure C3.1). I asked her to draw (Figure C3.2) a close up of the filter holes in the screen so that she could feel very safe about her level of control and protection of her emotions. She chose the flesh tone pastel to symbolize the ability to listen without judgment; the green pastel to symbolize kindness and warmth; the orange pastel to symbolize creativity; the blue colour to symbolize supportiveness; and the purple colour to "acknowledge the weak parts of myself that are angry at what goes on in the world; the hurt parts; the expectations; mostly "to be able to own that I am not a perfect person". Finally, Cynthia added a four-bar rectangle of colour symbolizing: disappointment, anger, strong beliefs and understanding. As she drew, Cynthia marvelled at her ability to use bright colours stating that she used to 41 feel ashamed of the part of her that was big so she only used muted, light colours. "As a woman I did not feel allowed to be these big colours. .1 had to be small...the reason I had to be small was so that I would not be completely alone," Cynthia and I processed the drawing in light of both her feelings of resentment, from different perspectives, for both the counsellor and the middle-aged lawyer. With two different perspectives of the same coin, Cynthia was able to consider, for the first time, the feelings of the counsellor. We finished by talking about the leap of faith between knowing something and living it. Cynthia felt she was learning a lot but was feeling very uncertain about living what she was discovering about herself. Therapist's log, session 3. I felt as though Cynthia was increasingly trusting of me. I felt as though we had established a good therapeutic alliance. I found myself genuinely appreciating her feisty spirit and her sense of humor. I still found myself feeling slightly wary of her possible passive aggressiveness regarding the starting times of the sessions. I couldn't help but wonder what part her testing of my willingness to be flexible regarding times was simply a test of her ability to feel in control with me. I resolved to happily go along with her needs. I found myself marvelling at how different Cynthia was from time of the outset of our work together ten days ago. She seemed markedly less moody. She also seemed to exude more energy. I reflected that we had spent a lot of time exploring her strong views: her black and white way of seeming the world.. .it was very interesting to work on the drawings with her and see that the colour she chose for the filter was GREY, yet the microcosm of a filter square was filled with many colours! 42 Figure C3.1. "The grey filter mask": This masks looked like a fencing mask but she described the broad edge as a door and the bum as a door handle. Both of these details were on the right (male) side. Figure C3.2. "Closeup of filter": Interestingly, the rainbow of colours ultimately formed the shape of a C, the first letter of her name! I wondered about the relationship between the rectangular-shaped colours in this drawing and those of the living room drawing from the first session. Cynthia cried when she drew today, she said she was feeling some shame. Session 4. November 12. Cynthia arrived today in a very good mood again. She was very excited about some positive changes in her relationship with her teacher at school. They had talked, and were able to iron out their problems. She was delighted and felt that a short rehearsal conversation we had had helped tremendously. She also volunteered that she had not binged or purged since she started these sessions. She also expressed concern that she had not exercised since we had started the sessions either. Cynthia began by reflecting on her past street activity, "it was probably one of the most empowering acts I have ever done. In my family, being used sexually was acceptable." Cynthia went on to explain that, in fact, the only place she really felt accepted "was on the street corner". We moved into talking about the difficulty and vulnerable feelings stirred up in her when she contemplated her childhood abuse issues. This discussion led into one about the formative stages of her bulimic behavior. She described the worst bulimic episodes which occurred for her when she was fifteen at which point she was binging and purging up to 20 times a day. The binging would literally unleash memories which were so awful that she felt compelled to purge out the feelings. "I would eat and have to get it out and it felt so good to get it out. I was an alcoholic and a drug addict then too. But the binging was so powerful - to stuff all that food into my body. I would make charts as to how long it would 43 take to be digested by reading books and going to the library (to know how long she could binge for before the first of the food eaten started to metabolize). I used to have charts and journals.. .it was so controlled.. .it would be binge, purge, workout, binge, purge, workout." I enquired as to how the eating disorder was different from her other addictions. "Well, eating is different. It just brought me to a bottom instantly. It wasn't accepted. I felt ashamed. It was too much feelings. It was so obsessed. With drugs, you were just out of it. The eating was first. Because I fuckin' hated my parents. I remember when I was 12 years old I said to my sister, "If it's the last thing I do I am going to suck those fuckers dry.. .(she wanted to break them financially) It felt very powerful because.. .where did the food go?.. .1 don't know! It was like I could be totally defiant. I can remember them not having any clue and I remember telling them I was doing this and couldn't stop and they laughed at me." Cynthia explained that the food was different in that it was the first and foremost way of making her parents pay...the drugs and the alcohol were a way to get out of the house but they were not as rewarding because they were more socially acceptable ways of acting out. Cynthia giggled, "Who wants to be with someone who sits in their closet in their bedroom and pukes all over the house?" For Cynthia food was her first and remained her last addiction. It began when she met a girl who threw up. Cynthia's first thought was, "this is such an excellent way to fuck people up. The next day I was shoplifting food and eating the whole house up." She paused for a moment and then added in reference to her parents, "but I couldn't throw up yet because I didn't hate them enough. The first time I purged, I became crazy. And it never seemed like an eating problem." Therapist's log, session 4. The general mood of the session was energized. I felt very happy for, and proud of, Cynthia's ability to resolve her fight with her school 44 counsellor. Cynthia appeared to be very please with both her handling of the situation and the results of her well-planned efforts. I was really delighted that Cynthia received acknowledgment for her hard work. She seemed genuinely thrilled at the realization of the possibility of her own positive power in the world. Telephone debriefing, week two.  Cynthia related that she was experiencing more sexual abuse memories and that this was really frightening her. She felt this week like she was not sure she wanted to come to the sessions for fear of what she might have inadvertently discovered. Session 5, November 16. The moment Cynthia arrived, she asked to use a phone so that she could phone a friend about whom she had been worried. Once she was confident he was alright, she began talking about a Narcotics Anonymous convention she had attended over the weekend. She had been particularly moved by a courageous woman who had told her story to a group of strangers. We began to talk about Cynthia's memories of what her father had done to her. Cynthia revealed she had never talked about what he specifically did and felt really afraid to do so. I asked her about the presence of fear around a responsibility and a guilt regarding somehow causing what had happened. She nodded wide-eyed and said slowly, "I always think it's written all over my face.. .like all the awful things. And I always think I am really dirty and bad. I feel so dirty." We spoke further about the NA woman. Cynthia recalled the woman said "she had a frozen screamin her throat." I asked Cynthia if she felt like she had a frozen scream in her throat. She started to cry, "I can't escape going through the pain of my past. My other fear is if I don't do the work then it's going to come out all sideways and crazy". She gave an example stating that she had contemplated going back to the street last year. This desire had nothing to do with sex, she had wanted the feeling of power back. 45 I asked Cynthia to draw a picture of what her body felt like when she was on the street (Figure C5.1). She took a long time to render the drawing. She did not talk while she drew but rather concentrated fully on the task. Once she finished the drawing, she announced that she was feeling "bleakness". Cynthia elaborated explaining that "the four blocks of colour are like a banner to the world and an internal banner as well - across my heart. And you have to be out there, you are big, you are open and you have to be sexual but you can't really show too much. You can't show any positive attributes except in your body. You can show spirit but only in anger. I smiled but I knew when to stop and if you don't you'll be a victim.. .it's like the way spiders eat their prey.. .they can't help it. It's just the way it is. If someone picks up on your vulnerability, they hate you because they have to." She went on to speculate that the colours represented her family members: the green represented her, the brown symbolized her sister, the black was her mother, and her father was represented by the red. She identified that she "hated her mother the most". I asked her if her intense hatred had to do with a suspicion on her part that her mother knew her father was abusing her and had turned a blind eye. She exploded back immediately, "Yeah!!! I hate her. I say to her, "where were you, where the fuck were you? I say that to her all the time." Cynthia continued, "When I try to thing of something that was good between me and my mother and my father and my sister, nothing was good. Even if the incident was nice, what I have to pay for that was horrible.. .so nothing was good. And when I think of my sister.. .it's mostly just sad, just sad... sad, sad, sad. At four and a half I was taking care of my sister...my mom was sleeping. I resented her, I didn't know what to do with her. I didn't really like her that much... she was a tattle-tail." Cynthia began talking about the word "no". Specifically, she remembered when she was eight years old, her father came into her bedroom, and although she repeatedly shouted "no", he had sexually abused her. As a result Cynthia felt that she held the word "no" in her stomach and "I feel really desperate when people say no...anxiety...my whole 46 body.. .1 lurch forward.. .1 could kill someone. That is how I have actually felt. I could go insane." Cynthia drew a picture of the word "No" (Figure C5.2). I asked Cynthia about what saying "yes" meant to her. She revealed that eating was a way of saying "yes". And it was a way of being left alone. She elaborated, "when you eat.. .you get all this armour.. .1 eat with my mouth open.. .it's tastes like shit". She gleefully described that she loved to eat without any attention to manners especially since her father had not allowed her to eat that way when she was a child. Therapist's log. session 5. I was struck by Cynthia's great concern for the welfare of her friend especially in light of the fact that she viewed herself as quite cold and uncaring. I was similarly struck by the burden she felt of having to mother her younger sister when she herself was still very young. I did not sense she ever was able to simply be a child. I also wondered about her continuing to step into that role with people like her suicidal friend. It was a role she seemed to know well. I was also interested in her dance with the prospect of exploring her childhood sexual abuse issues. She seemed so strongly drawn to the precipice of those memories and yet terrified that the cliff would crumble and she would fall into a bottomless abyss of pain. Figure C5.1. "The feeling of being on the street": The egg shape suggests female fertility and yet it is depicted in the colour brown; the colour is excrement. The red may embody both sex and anger. Cynthia described the banner as both "protection" and an "announcement". The entire picture is surrounded in a sober and death-like blackness; the colour she ascribed to her mother. The only island of health maybe the colour she reserved to describe herself: green. However, Cynthia did not interpret green as healthy, she saw it a just another colour. Figure C5.2. "No": The colours black and red suggested darkness and anger, bleakness and sexuality. They were rendered in a somewhat box-like form but were also 47 squiggled and confused. They did not suggest any sense of real control, order, or authoritativeness. Session 6, November 19. We began by discussing Cynthia's overwhelming feelings of intimidation whenever she found herself having to interact with middle-aged men in positions of authority. She explained, "I don't feel as inadequate around men as I do around women. When a man raises his voice and says the way it is going to be, I get really scared. When women do that, the opposite happens, I know I could hurt them. I am not afraid for my life...even though my mom was physically abusive, I don't get the same thing from women as I do from men. I have been sexually abused by men and by women, but my father never hit me: my mom hit me." We agreed to undertake a guided imagery exercise wherein we sought out her maleness within in an effort to better understand the intimidation she felt around certain types of men. We began with Cynthia providing a definition of her female gifts. She cited: the ability to know what's important; a willingness to change; acceptance of others; and physical strength. When I asked her cite her male gifts, she was initially stumped reporting only that her body felt, "kinda sad". Eventually, she was able to identify some positive male attributes which she felt she embodied: the ability to be different in different places, be a chameleon; the ability to get things done in order; the part that knows there's a time and a place for everything; the part where I want to be successful and want people to look to me". I asked Cynthia to cluster the male qualities such that we could talk with them. She saw them as a vertical line. We asked the line for advice regarding how to deal with intimidating men. Cynthia reported, "they say the reason why I am like that is because I am afraid. I think I have to do some work around my (long pause).. .1 have to do some work around being a sexual abuse survivor. I don't have the walls and the masks anymore to hide my fear. Before, it didn't happen. I would not talk to them or be rude to them or make them not like me." 48 When we finished the exercise, Cynthia reflected on her reactions to men, "I could live in the world very easily without men. They are useless. It's hard for me not to be angry with men when I see what goes on in the world. And it's hard for me not to be angry when I know what happened to me. I feel repulsed by men. The look of them, the touch of them, their skin. The way they talk the way they move. Stupid, ugly people. Useless!" I asked how bulimia and her repulsion of men go together? She began to weep, "I feel like I am contaminated. I am contaminated by their sperm, their bodies. They contaminate the air. They contaminate me everywhere I go. They look at me walking down the street I am contaminated. They ruin me." I asked Cynthia about what it was like to have sex with her boyfriend, Robert, "I feel ashamed. Gross. There's something about sperm.. .it feels very relieving to me when I throw up...get it out, just get it out. Sperm. I can not handle a man putting sperm inside my body. I just will not allow it." I asked about the significance of purging. Cynthia growled with a twisted smile, "That's the real pay off. It's like fuck you ha ha. You can't touch me now. But the only thing is then I feel like an empty vessel having to fill myself up again because the only way I can protect myself is with food. And without it in my body I am totally vulnerable. If I puke and go work out, I am totally afraid...where if I have eaten and I don't throw up I feel ashamed and I feel fat but I don't feel like someone is going to attack me. What's more important? So now my desire to throw up is not so great because I know what the outcome will be but sometimes it's worth it. It's like being on a bad trip. It's like doing acid for all those years and then suddenly it turns on you. It all turned on me." Cynthia finished our discussion by describing wanting to get something else, besides sperm, out of her body: it was a monster represented by "big faces, big people, loud obnoxious, ungraceful, knocking things over, so uncaring, I always thought my parents were so stupid". 49 Therapist's log, session 6. In spite of the very challenging and intimate material with which we dealt, Cynthia remained very energized and presence throughout the session. I was struck by her courage and by her desire to get well. I found the guided imagery exercise exploring Cynthia's male qualities to be very telling. I suspected if she could reclaim her maleness, some of her dirtiness feelings might be able to dissipate through a self integration. Telephone debriefing, week three. Cynthia marvelled she had never before talked about the things we talked about this week. She said she was feeling good; that she was starting to feel "more stable". She was also noticing changes in her behavior, feelings, and patterns. She said she had not purged since we had started working together; a duration which she described as a "long time". She also identified that she still had not exercised since we had started working together. Session 7, November 23.  We began by discussing how Cynthia felt that her manipulative behavior had always gotten her in trouble. She felt she was constantly manipulating people to get what she wanted. She stated resolutely that she did not want to operate that way anymore because she liked the quality of her new life and liked what "doing things by the book allows me...before I did it because a part of it was thrilling, control, something to do". I asked Cynthia from whence she was now getting her thrills and her sense of control. Cynthia began excitedly talking about the high goals she had for herself and that she was beginning to believe in herself. She said she daydreamed about being successful, and believed that she had the ability to do so. I asked Cynthia to elaborate on the difference between short term thrills and long term thrills. She immediately answered that the thrill was in "having a goal, setting a date, doing the research and getting what I want. The thrill is in doing the steps... the thrill is when people say I am doing a good job". I asked about the difference between a binge thrill as opposed to a long-term thrill. Cynthia clarified, "Binging is a sick thrill: the secret, the shame, chemically in my body, it's a 50 thrill to be in crisis. It's like a punishment. You know what motivates me is fear, fear makes me eat, throw up, exercise, see my friends.. .fear of rejection, being fat, being unbeautiful... looking in the mirror. My body starts to manifest things that aren't really there. I know it's not really true but it just starts to get bigger, folds of flesh, stretching, I can feel bigger parts even though I know that's not really true". We explored the impact of exercise on Cynthia's way of being in the world. She explained, "I don't feel safe when I get out of aerobics. I don't feel physically safe...I feel like I am going to be raped. But when I finish stairmaster, I don't feel that way at all. Maybe it's that there are lots of women in there. In aerobics, if you are not totally perfect, you are somehow not good enough." I asked Cynthia to elaborate for me on the difference in emotional experiences for her between aerobics (female) and stairmasters (male). She stated, "In aerobics you have to be perfect. It's about looking good and being really coordinated. It has a lot to do with image. Women compare with each other and stare at other women's bodies in ways that suggest they aren't good enough. If I am in the middle of an aerobics class I can't be sure that I am not going to run home, binge, and purge. Because looking at other women's bodies...comparing myself, punishing myself.. .1 feel I have to be thinner. I go home, feeling totally lost, eat big time and puke. It's just insane thinking.. .but who's standards am I working on? This is insanity.. .living my life based on what these fucldn' magazines tell me. If I look at my skinny aerobics instructor and say I want to look like her I am saying I want to look like a tit-less, ass-less robot. I don't want to look that way I want to look like a woman.., that's what I need to tell myself." Cynthia paused and reported with a knowing smile on her face, "The little light is getting this intense head rush". We moved into a guided imagery exercise to talk more with the light. At first, she has trouble locating the light in that she felt it was hidden behind some food. I asked her to dust off the food, which she did and then said, in a little girl voice, that "the light was afraid of being assertive". After some coaxing, the light 51 volunteered that it felt Cynthia spent too much time in her mind. And if she did access her feelings, she was unable to actually think and feel at the same time. She observed that she would like to be more than "black and white". She paused to reflect for a moment that she did not think about herself as fat on the weekend. I observed that her weekend experience sounded like 'colours thinking'. The light continued talking to Cynthia encouraging her to "give it a try, be yourself. It might be true that other people don't like you, but it doesn't matter." Cynthia suddenly exploded, "why is everyone else's 'appropriate' so fucking important? Their rules are so much more important than mine? That's why that stupid lawyer thing happened. I am selling myself out. I am mind reading. I could stop asking people what their opinions are". Suddenly Cynthia noted that the lawyer was useful learning for her recovery. She appreciated that he helped her to listen to how she felt, "if I want personal power, then I have to keep it not give it away". After we completed the exercise Cynthia brought up her experience of the sitting beside fat women on the bus. She observed that she no longer felt afraid of them, but felt compassion for them and wanted to give them Overeaters Anonymous pamphlets as a way to offer help. Therapist's log, session 7. I was fascinated with Cynthia's experience of vulnerability and lack of safety around certain types of exercise depending on the fullness or emptiness of her stomach. It felt as though, without the "armour" of food and the feeling of heaviness, she did not have enough protection between her emotional self and the rest of the world. Session 8, November 26. Cynthia arrived with a fistful of food she had stolen from a tray which she had noticed in the Counselling Psychology faculty staff room. She appeared very upset. After scarfing the food she had stolen, she asked me to bring her some more 52 since I was going upstairs to return the therapy room key. I did so. She settled down, leaving her coat on, hunched over in her chair, her arms and legs crossed. Cynthia immediately launched into a story about an experience she had just had at an Alcoholics Anonymous meeting she had attended. It seemed that "a big burly man" whom she did not like anyway had been picking on a woman at the meeting. Cynthia had defiantly jumped to the defence of the woman which, in turn, incurred the wraith of the burly man. He screamed at Cynthia, "like an animal", and shouted threats and obscenities at her. Cynthia was so frightened by this man that she left the meeting. She felt like hiding and binging. Instead, she chose to talk with some people about her experience and she worked on her resume for several hours. Things changed when she went home that night and told her boyfriend about the man at the meeting. He became very angry and his anger deeply frightened Cynthia. She said she started to feel like she had "been raped." She was shaking and crying, "I started having all these flashbacks.. .all the anger feelings, my parents were like that, I remember being raped and the faces were like that, a couple of guys that were angry...a guy I lived with was like that, trying to intimidate me with physical force. I have been threatened so much. When that guy was threatening me I just stared at him. I felt so weak. I have to look at my part in it too. Now I feel like a piece of shit. I feel so weird. I hate Robert right now. He is the one who made me aware of how bad the situation was." I asked Cynthia about what Robert's display of care and concern had stirred in her. She began to cry, "when he shows that he cares about me it really frightens me. It's a very scary thing. And then having these people support me. I could have had a million people support and it wouldn't have bothered me before. It makes me really angry when people acknowledge me." Then Cynthia spoke more about what had been stirred up in her as a result of her confrontation with the burly man. She roared, "I am just violated; the same way I always 53 felt when I was younger. Except it doesn't feel comfortable anymore. It doesn't feel safe. I feel RAW. I feel on edge. I feel like my behavior is weird. I talk constantly. I am kind of fake. I feel like I am not real. Part of me does not want to accept the fact that.. .1 keep on feeling like it was my fault that man hated me that way. It's something I put out in the world to make him do that to me. Then there's this other part... 'how dare he hurt that woman?' Then another part says. He is a lot bigger and stronger than you, and she doesn't need other people to take care of her she can take care of herself. And then I just feel like a fool. I feel like In some way I made him treat me that way. I keep on looking around for people to blame me for that." Cynthia began to cry, "What am I supposed to do smile? I want people to leave me alone. I am not going to sit there and be open bait. It's just like I am not safe. I don't feel safe. I can get beat up at an AA meeting. I walk down the street and some guy is going to attack me. And the hatred. That's what really got me. His hatred toward me. Men hate them (women). Men batter them and bruise them and rape them and hurt them all the time because they hate them. Men hate women." I asked if Cynthia if she felt her father hated her. Without missing a beat she shot back, "Yes!!! I totally believe it. I think he hated my mother. I think he hated his mother. I believe my father is a total woman-hater. He totally hates women." I asked Cynthia if she felt her father's feelings about women might have been ingested by her somehow. She replied that her father's thoughts were throughout her being. She reflected further on her father, "I think my dad wanted to be loved so much but he was so angry and he was so confused. He did not know.. .nothing ever satisfied him. He could never be loved enough. He would be so cruel, my God, and then he'd want to be loved. Cruel to everyone. My mom, my sister, me. To me. He repulses me beyond belief. The sound of his voice on my answering machine is enough for me to binge and purge for a week. Just like fuckin' repulsion. Total.., get the fuckin' shit outta me. Like I exercise, I talk on the phone, I 54 breath. Really hard. I erase his message. I read the Courage to Heal book, I don't know. I just do something because he makes me ill." Cynthia carried on talking about how her father wanted to come visit her and her sister. She talked about needing really strong boundaries, that she wanted him "to die", and yet she felt "guilty" at not returning his phone calls. "Then I thought why should I phone a man who has sexually abused me. He makes me so SICKENING. He makes me so UUUUUGGG...the thought of sitting in a restaurant. His body.. .he's disgusting." I asked Cynthia to draw her feelings. She began right away and furiously drew three pictures (Figures C8.1, C8.2, and C8.3) without speaking. Once they were completed, she began to talk, "the first one I was thinking that I wouldn't think and I wouldn't feel. I feel like I am in a jail cell. And it's like nobody can really see it and I am even wondering if it is there but it is very much there. The whole world is like a jail. It's like living in hell. It seems like they are always there. Sometimes they are not there as much. I don't think it's possible for me to live my life without them there. I don't think it's possible for a woman to be free. I don't think I will ever be free. I will always have to play second fucking fiddle to some man. I will always have to suck some cock somewhere along the line. It doesn't matter what I do. I have a decision. But even in the decision, I always have to sacrifice my integrity so I can eat my food, do this, do that. I always have to hurt somebody or somebody is hurting me in order for us to get what we want. It's always a catch 22. Nothing is ever truly okay and good. Sometimes I feel really free. But usually, I am not safe." We determined to do a guided imagery exercise to talk with the little light about her feelings. Cynthia discovered that the light was "very small and pink, feeling very scared". I asked Cynthia if she could encourage the light to spread pink thorough out her body. She was able to do this and reported feeling more peaceful and more comfortable. I asked Cynthia if the light had any suggestions...she answered, "to stay calm, and pray. Pray to God and ask God to take care of it for me 'cause I can't do it." 55 Therapist's log,. session 8. Cynthia was clearly extremely agitated, experiencing both an immediate emotion in response to the confrontation with the burly AA man. I was stunned at how scathingly critical Cynthia was of herself. It was as though she felt responsible for the burly man's wraith; as though she felt responsible for her father's sexual misconduct. I felt as though she did not want to be in her body, or feel what was in her body. Figure C8.1. "Red Heart": The image looked like a diamond-shaped heart, with a black line scorched through it, permeated by a stain of brown. The drawing felt very raw and angry. Figure C8.2. "Flower behind Bars": This drawing felt childlike. It depicted something that is normally associated with beauty and joy and yet the image was imprisoned. The colours at the top of the picture looked like storm clouds and they too were behind bars. Figure C8.3. "Third Drawing": This piece felt like the storm had broken. Pink and peach colours emerged through the work framed by remnants of the storm colours of brown and red. The colours were still encased, however, by black, vertical and horizontal lines. Telephone debriefing, week four. Cynthia said she had learned that she does not want to be a victim anymore. She also expressed that she was learning to take care of herself. She described crying for "two hours straight" on the weekend. She experienced a resurfacing memory of her mother not caring. She was also feeling a lot of emotion around "being the odd man out". Interestingly, Cynthia felt a "connectedness to God". She explained this sentiment emanated from our talk with the "little light" which told her "to pray". Cynthia then confined that I am "the only woman" with whom she has ever connected and she is worried 56 about what will happen when we are finished. Finally, she raised the issue of her anger at her father. He phoned on the weekend. And she felt furious. Session 9, November 30. Cynthia appeared uneasy today. She began talking about when she overeats. She said she only overeats when she purposely sets herself up to purge. And the purges happened when feelings of repulsion and memories came up that she didn't want, "dirty feelings of loneliness, insecurity, fear...a lot of times loneliness, or if I have made a mistake. But I feel stronger...I have experienced a real frantic feeling of never wanting to feel the purging feeling again. It happened the day I met you. The day I signed that paper. Saying, okay I have an eating disorder was a big thing. The second thing was talking about it, saying I have an eating disorder." Cynthia moved into talking about how difficult it is for her to talk intimately with women, "It is more frightening to be intimate with someone that to be anything else." Then she expressed her deep concern about her fears of abandonment over our sessions ending. I acknowledged her concerns and asked her if she had done as I had suggested and double checked on the therapy program she had set up to follow our work. Cynthia said she had called but was worried that the people at her next program sounded cold and uncaring. Cynthia began talking about providing her own support system. I responded that she seemed to be working toward that now. Cynthia quickly answered that it was because she knew she was seeing me twice a week and felt like someone was watching over her. Cynthia also took a moment to verbally lacerate a past drug and alcohol counsellor whom she felt had really let her down. She was furious that we had done so much in such a short time and so little had happened over a year with her past counsellor. Cynthia appeared very unhappy and agitated. I suggested we do a guided imagery exercise to help her feel more centered. As she moved inside, and she immediately discovered a big lump of anger and frustration in her stomach. I asked Cynthia to breath deeply and image a funnel from her feet to the center of the earth through which poison could move when she exhaled and from which fresh, pure energy can emanate when she 57 inhaled. Cynthia reported feeling much better. I introduced her image of pink light into the exercise, asked it to sterilize and heal any areas that had poison in them, and to spread pink light throughout Cynthia's body so that she could recognize and love herself and feel centered in her power. Cynthia calmed down considerably. She finished the exercise and reported feeling much happier. Therapist's log session 9.  Due to work constraints, Cynthia was unable to meet me at UBC for our appointment. So, I agreed to meet her at her place of employment. I was a bit taken back by the strength of anger Cynthia harbored toward her previous counsellor. I confronted her about the possibility of the drug and alcohol counsellor being a projective screen for her fear of abandonment by me. Cynthia adamantly denied that suggestion and determined that she was in fact angry at herself for not taking better care of herself by leaving the drug and alcohol counsellor sooner. Session 10. December 3.  Cynthia arrived with a bag of lolly pops and proceeded to suck on several of them throughout the session. We began by going over the plan for her future therapy. She took a moment to tear into her past counsellor again. She also informed me that she was sure she will have a full-time job soon. We began talking about Cynthia's food intake at which point she said that she threw up for the first time since we began seeing each other after our last session. She said she felt good when she left the session but went straight into a store and bought a binge food: potato chips. I observed that she may be worried our sessions are ending. Cynthia said she has thought about this but that she really did not feel that was true. However she then immediately talked about how far she felt she had come during these sessions especially since she had been in "desperate need". She felt the counselling work she had done in the past "was useless. I never really thought that going to counselling would help me." She began talking about how tough I had been on her in terms of both of us working to find her a solid therapeutic path for her to follow when we had finished, "when you said 58 it, it really hit me; that, like I always do, I would leave myself open to not going anywhere. And it made me really fucldn' mad that I would have done that. If you hadn't of said anything, that is exactly what would have happened." We moved onto to talking about the nature of her upcoming treatment opportunities and she registered her great fear that she might have to work with men. She announced that she would be much better off if she never had to see or deal with men again. I asked her what protect she would be afforded if there were no men in her life. Cynthia reasoned, "because there won't be a chance that I will get hit, or beat up, attacked, approached, undermined, embarrassed, put down.. .those chances are virtually non existent without men.., women don't do the same thing." I asked Cynthia about was going through her mind when she binged and threw up on Monday night. She answered, "It was like I was isolating myself. I couldn't really understand why I was doing it. I think I was really, really angry at the fact that...my drug and alcohol counsellor has files on me." Cynthia felt not only abandoned by her ex- counsellor, she felt very vulnerable. I asked Cynthia if she was not worried that I too would have files on her. She responded, "When I look at you I get attention. When I talked to her it was like she is staring out the window. I know you know what it feels like. I know that. But with her I don't. I don't really feeling like you are leaving. I feel like I am going on. I am not resentful it is not going on anymore. I don't really feel like it is over. What I have been angry at is myself. I was going to leave myself open and not get any help afterward. And it makes me fucking angry that in six weeks I could get more in a week, in one session, that I ever got from her (the drug and alcohol counsellor). I think maybe I cried twice in a year with her. I never got the right help and it makes me mad. That is one of the triggers. It is easier for me to get angry or to act out in anger than it is for me to cry." I asked Cynthia about any possible connection between the drug and alcohol counsellor and her mom. She noted that she broke off relations with her mother around the time when she first started seeing her old counsellor. 59 Cynthia began crying about the "incredible fear and total change" since she made the decision not to get near her mom. "It's just that leap of adulthood even though I feel better that she is not in my life. By saying that it is over (with her mom) all the other abuses disappeared too. I started to support myself. It was a good thing but it is really scary. I am the one that is doing it. There is no turning back. There isn't a mother to fall back on." I asked Cynthia about what a perfect mother would have to do to help her. She responded quickly that she did not want anything to do with any kind of mother at all. She laughed uncomfortably, "the thought of having one is nice. But the responsibility of having a mother is too much." Through tears Cynthia shouted, "I just don't want one!!! I don't want to put the energy into thinking about this woman that would be so wonderful for me. It's very hard for me to put any credit to a mother. There is no mother inside of me. If I am my mother inside of me it makes me ill!!! I don't want that even if it is good. I really don't. I DON'T WANT ONE!!! It's like a thing, it's like a lacking think. When I let go of her I didn't pick up a piece of myself. When I let go of her a piece of me went with her. The one who is quick on my feet, who is a total survivor, who can think and do in all situations. Who is totally fake. A person who is really strong. And now I am really intimidated by men, by this, by that." I commented that those aspects of her mother sounded like a warrior. She agreed wholeheartedly. I asked her to draw a picture of the warrior (Figure C10.1). As she drew she talked about fighting back at her father but that it was not very successful. As soon as she finished her drawing she began to interpret it. She saw the orange as creativity; the red as a healthy anger, "It's not a bad anger, it's a good anger"; and the blue, green and purple as "woman parts." In particular she saw the last three colour as representing, "the struggle. I think now what I realize are the special things that make women special is that, I struggled in my life, but my mother struggled and my grandmother, and her mother...and so 60 we have something inside of us is very powerful because we came up out of struggle. The pain turned into something that made up special." Therapist's log, session 10. I felt it was no coincidence that Cynthia purged for the first time since our sessions began following our last session wherein we spoke about termination. I suspect Cynthia was worried about our union dissolving before she felt ready for that to happen. I was also considering another possibility which was the emotional storm stirred up in Cynthia by the burly AA man. Cynthia was very concerned about her safety in the world. As a woman, I felt her concerns to be totally realistic; unrefutable. I was intrigued that Cynthia was absolutely unwilling to even indulge in a fantasy about mothering let alone actually consider the possibility of accepting that from anyone in real life. It felt like she protested too much. Figure 10.1. "The Warrior": Cynthia drew an image of the part of herself she lost when she stopped communications with her mother. The image was shaped like a mandala. It was depicted in strong, bright, rainbow colours. Interestingly, the emotion of anger was rendered as distinctly separate from the female components of the drawing. Telephone debriefing, week five. Cynthia reported that she was feeling better all the time yet also felt more emotional. She expressed surprise at how much she was crying, nor did she feel in control of her sadness. She also noticed that she was picking a lot of fights with her boyfriend. She said she felt like a "bad person" about her boyfriend. She still felt very shaken by the AA experience. In general, she felt very frightened at the prospect of even looking at men let alone talking with them. Session 11. December 7.  Cynthia arrived eating a cornpuff snack. I begin by finally commenting that she had arrived at the last few sessions with food. Cynthia replied that she has not been eating lunch lately. I asked if it may also have anything to do with needing to keep emotions at bay. She chortled, "Obviously I eat to hide from my feelings. 61 If anything is on overload I eat." I commented that she didn't eat like this when the sessions began. She shrugged that she did not have very good eating habits. She also noted that she had had a couple of puffs on a cigarette of late. Cynthia began talking again about how difficult intimacy was for her, "When I look back and think about my life. Except for my parents, I never let anyone else care about me. So I don't really have any experience with people caring about me. After I left home, I never allowed anyone to care about me. If somebody was showing caring, I didn't like them anymore." I commented the cost of accepting care had been too high...she agreed. She then talked about Robert and how difficult it was for her to experience him getting mad over the AA man. Cynthia said she was starting to allow people to care but it was not easy. "If they care, I have to let them.. .it's too much work. .all at once". I asked if the word, 'work', could be replaced with the word, 'vulnerability'. She agreed. I asked if the extra fights with Robert might have been veiled attempts to push the intimacy away. She agreed. I asked if the intimacy with Robert was the first she had had with a man since her dad; it was. I asked if this could have been stirring up those unresolved memories. She identified, "I am dealing with all the yesterdays. It's not about him and me. It's about me and somebody else. It wasn't just my father who abused me." She described Robert reaching for her in a sexual way the other day and how she felt, "mortified. Totally awful. I was scum. Everything about me was so awful it couldn't be touched. I was repulsive." But Cynthia responded by listening to her feelings, rather than worrying about pleasing her boyfriend, she stopped his advances. She explained to him, "I am more important that you are. My recovery is more important that you are.' It felt good... really, really empowering." We talked about the safety and preparation needed to really be able to talk about her issues with her mate. Cynthia felt she needed him to be strong. She felt she needed to stay away from him for a while. I asked if there was a connection between deciding not to see Robert, her school finishing, these sessions finishing, and looking for a job. Cynthia acknowledged she had been thinking about that. 62 We summarized some of the work she had done in our sessions including: beginning to know what was best for her at any given time: shoring up her boundaries; being able to express her feelings more openly with people; and developing useful, empowering, daily tools like the imagery of the little light. Then out of the blue, Cynthia announced she had called her estranged sister for the first time in six months. She explained, "I needed to hear her voice. I always have felt responsible for her." I asked her how she felt hearing her sister's voice. "I felt really, jealous. Angry. And happy. Why does she sound so mature? Like a comparing.., she sounded so together. She is driving a car. I am really jealous of that because I am totally afraid to drive. She seems so well adjusted in her life. When I was 20 I was totally fucked. It seems she's so much better in the world. I don't really related to her. She's a follower. She doesn't seem like my sister. Whenever I talk with her I think, 'maybe my parents weren't so abusive. Maybe I am making this up.' We had a really bad sibling rivalry. My mom pitted up against each other." We determined to do a guided imagery regarding going inside and exorcising anything inside of her that did not feel like the real her. Cynthia moved inside and immediately gravitated to her brain where she saw cigarette smoke-like blue, grey fog. She reported "it is a downer.. .it's depressing me. Because I want to have everything I want. But I am not getting it.. .negative thinking." I asked her what she would have to do to burn the fog off. She wanted to give it away to God, who is 'up there'. She determined she could give up the fog through the pores in her head and hair follicles...she felt she needed to "resign to it. Admit that I can't do it. That it is not up to me and stop doing the outcome instead of letting it happen naturally. I am ripping myself off. Not using the light, I will always be in the same place." We focussed on the fog being sucked away to God. This took a few minutes. Cynthia reported that the light and God are different but that they are made of the same thing. She determined the light was closer, and was a pale blue colour. I asked Cynthia to allow the light to fill the space in her brain that has been left by the fog. 63 She did this and it enabled her to feel safer. She also reported that she was making her body warmer by generating energy in her solar plexus. When Cynthia finished the exercise, she began talking about wounded people walking the face of the planet causing so many problems. I asked about the food. She reflected, "I have to think of things politically. To puke is to say to someone, 'You are right. I am a loser, this is woman in chain laying by a toilet and throwing up all my food.' It's almost like telling my father that he is right." I asked Cynthia about her binge/purge last Monday. She answered frankly that she did it because she felt "afraid"... .now it's hurry up life". Therapist's log, session 11.  I was not in the least bit surprised that behaviors such as the binge/purge, eating in the sessions, and a little stab at starting smoking again have cropped up at the end of our work. They felt like hollow efforts however. Cynthia appeared to be thinking ahead about our sessions ending. I sensed she was not sure if she was ready to fly on her own, to trust her instincts without my support shoring up her mixture of bravado and genuinely courageous pattern-forming of trust in, and love of, herself. Separation and abandonment issues have certainly cropped up in the last couple of sessions. Cynthia asked if I could continue to work with her. The component of sibling rivalry came up in this session. It felt as though Cynthia was irked by her sister's progress which functioned as a benchmark of the progress of her own life. I was intrigued that "God" would take away her confusion which was manifested in the 'fog in the brain' image. I was not sure at to the meaning of the pale blue light. Session 12. December 10. Upon my arrival at UBC, I received a message that Cynthia had phoned and left a message saying she felt unable to come for the session because she could not bear goodbyes. Ironically, this was the last day of her school program as well. I phoned Cynthia to rebook an appointment and she explained she would 64 be busy from here on in and would not be able to come. I decided to make a concession and go to her house to be able to terminate properly. Cynthia began our last session by talking again about how she was uncomfortable with intimacy, especially with other women. Cynthia explained that she had really acted out by pushing people away at her school ceremonies earlier that day. She reported she was really uncomfortable feeling support and love, "it made me ill". She went on to talk about the fear she felt in having succeeded in finding a job. She elaborated, "It's like I have to be an adult. I have goals. I have dreams; having to be mature, have goals, aspirations; having to give up my mother and my father to heal is a mature thing. Standing up to them. I stopped the abuse. I did something for myself and it depresses me. There's a lot of guilt attached. I get confused. Maybe I should let bygones be bygones." Cynthia was pleased she had a job. But she added, "I am in pain. I am totally mad because I have to change. I am totally scared." I asked about how this pain was different from being on the street or when her dad abused her. She mused, "It's like ...I didn't really have pain. It was dull. That's all I thought I deserved. That's all I thought I could do. I liked it because it was an excuse. And now I have no more excuses." We talked about the difficulty of a transition to a new life. She protested, "But I wanna find a way to love myself". We talked about transformation as a painful process. Cynthia began talking about how the white light had helped, "I have a total belief in that white light now. You wouldn't believe it. I think about that white light all the time. One of my affirmations for last week was, "I, Cynthia, believe in my white light. I get upset and I say, 'white light.' I know that it is there. That was so valuable. Everytime we did that. I feel like I have changed. It's like I am much more than just me. It's like there is a whole different person running around inside of there." Cynthia identified that it felt like God. "The white light doesn't make anything seem impossible. The white light is very serene. It 65 very powerful. Even when it is very small. IT is so steady and firm and it is totally clear. Whenever I do the white light thing I feel. I am in the hands of God. Even sometimes when I am doing it I get a smile on my face. It's like the only place in the world where I can go where I can really smile. Where it is like glad. I don't know. I never really experienced that before. It's like serenity. It would be so amazing to walk in the world one day, a 24- hour period to feel protected and safe." Cynthia began talking about how dumb she had initially thought the guided imagery exercise was. She talked about the day she met me. She felt she was at the end of her rope thinking of "living on welfare and eating salami. I was so desperate." She was too embarrassed to admit to being a bulimic at the OA meeting. Earlier today, Cynthia had stood up in front of a whole group and admitted she was a sexual abuse survivor. We moved on to the TST exercise. Cynthia interpreted her first drawing (Figure C12.1), "How the world sees me", "I know the world sees me as loving, a spark for life, a zest (the red); the middle is soft and energetic (the yellow); black is the shadow part of me. The red is my anger for life, not bad anger.. .like passion. I think anger is good. It can be perceived as angry.. .it is like survival. The blue is what people see on the outside. People see the blue and then it takes people about five minutes to see the red." Of the second drawing (Figure C12.2), "How I see myself when I looks in the mirror", Cynthia said, "I see a person who displays pain and anger.. .acting out right? (the wiggly part). This is me acting out and what is hidden underneath. There is like power (purple), but then creativity is hidden underneath (orange). And then there's feelings of darkness (brown). The pink is pain, it's different, like growing pain. The blue is what I want to show people: normal, alive, and fun and zest and energetic and fighting. I think this is me." In reaction to the final TST drawing (Figure C12.3), "My Inner Healer", she laughed gleefully, with sparkles in her eye, "it's alive". The white light was, in fact, a rainbow of colours. 66 Therapist's log, session 12.  I felt a bit frustrated by Cynthia's last minute decision not to come to the final session. I also felt compassion for her fears. I shored up her decision through complimenting her on listening to herself and taking care of herself. Part of me felt manipulated; part of me felt that my willingness to go to her was what she needed at that moment. Much of this session focussed on her fear of having to grow up; being 'an adult' taking responsibility for herself. We also explored the fact that getting over bulimia doesn't mean an end to problems. She recognized that it may even mean MORE problems in that things were no longer masked. As a result, more feelings and more awareness may come through. She was realistic and philosophical about the discussion. I was impressed by the depth of her appreciation of the white light. I was increasingly struck by her reports of conversations with her version of God - and the peace this seemed to bring her. Figure C12.1. "How the world sees me": The image depicted looked like a triangular mandala - somewhat like the inner healer image drawn in the first set of the TST. The pink/purple core felt like a sort of feminine/spiritual symbol of some sort. The green may have represented health; the orange creativity; and the blackness, her shadow. The outer layers felt mixed with blue for male power and a healthy dose of red, perhaps protective, anger. Figure C12.2. "How I see myself when I looks in the mirror": This drawing felt quite different from anything Cynthia had done before. There felt like a wonderful mixture of light and dark colours. It felt as though Cynthia was welcoming in her whole spectrum of emotional colours. Figure C12.3. "My Inner Healer": The white light which Cynthia described as "alive" did, in fact, look like some sort of amoeba, or an island of sorts. The progression of colour was quite different from the other drawings. The use of flesh tones were new. The 67 placement of the human flesh tones was interesting (the inside and the outside). Joyous yellows were also echoed on the inside and the outside of the image. Telephone debriefing, week six. Cynthia described herself as feeling very good about herself and her world. She reported feeling "much more human.. .if I overeat, I overeat. If I throw up, I throw up. I am human." Surprisingly, and to her delight, she had started to see her estranged sister on a regular basis again. Regarding our work together, Cynthia said that she felt very cared about and that she had never felt threatened. She described our sessions as being "a real commitment. You really made a difference in my life...a real gift. I am starting to believe in myself. I am really feeling like I am becoming a woman. It's a grounded feeling. I welcome the responsibility. It is achievable. It is so nice to be relied on, be respectable. I am now thinking I might be ready to work with a male therapist." Sonya Session 1, November 2.  Sonya arrived chewing gum. She immediately denounced her drawing ability but gamely began the warm up drawings. As she drew, Sonya talked about her dislike of Christmas; and about her inability to travel due to her agoraphobia. Sonya had not been able to leave the city limits for 18 years. There had been times when she had not even been able to leave her neighbourhood. Sonya also talked about her boyfriend, Jason, exclaiming she appreciated him because he wouldn't let her "play games of manipulation." Sonya talked about her weight; about how much she had binged and what a terrible day she had had. She explained, "I feel very very fat, I am still binging all the time. I am up to an uncomfortable weight right now I am very unhappy with it. Nothing is changing with that. Food is still constant, constant, constant." Sonya speculated that she ate especially when she felt her security was threatened in anyway, adding that she was in a business with no security. 68 Sonya finished the first drawing (Figure S1.1) and reacted to it, "I started to feel really funny when I did this (points to the roots of the tree and the grass) I just thought of my grampa. We used to lie out in the grass all the time when I was a kid and he would tell us stories. I dunno why it bothers me." The second drawing (Figure S1.2) depicted Sonya's sister's children. Sonya talked about how alike she and her niece were. She explained emphatically, "Well, she looks like her mom but she's got my hair and my temperament and my tomboyness and independence. Don't touch me, I'll come to you. I've done that all my life. She's so much like me." And of her nephew, "He's very different. He is a loner. And she is the performer." Sonya felt that she was like both of them. She spoke wistfully about the children's existence, "They got people there for them all the time and they are so well brought up. They are taken care of and their teeth are taken care of and their health is taken care of and they are loved and they are taught really wonderful values". Sonya lamented, "We never had anything, we were struggling all the time. We had second hand things. We made our own things. I still feel bad, I still feel like a victim. I still feel poor me a lot". Sonya explained the third drawing (Figure S1.3) was a picture of a travel fantasy which she felt she would probably never realize. Sonya began the TST drawings whilst telling two stories: one of a woman whom Sonya perceived to have been very cruel to her, the other of a woman who had thanked Sonya for helping her with her recovery. As she drew the first TST drawing (Figure S1.4), of what she felt the world saw when they looked at her, Sonya mused, "I'd like to draw a wildebeest, but I don't know how to draw it; a wildebeest which is wild and untamed, vicious. Yeah, people think I am weird, and wild, really wild, and some people think I am funny. That's what I think". She then took a couple of minute to quite ruthlessly denigrate her appearance. In response to the second drawing (Figure S1.5) of what she saw when she looked in the mirror, Sonya snorted, "Depends on what day it is". Then she muttered, "Fat face. I always feel as though I have three chins. My waist is very small on certain days. Not today. Horrible today. I am so fat today." 69 As she drew the third drawing (Figure S1.6) of her inner healer, Sonya volunteered, "It doesn't look that.. .it's a wizard my inner child stuff with my grandfather. And he had a shalaylee in his hand. Which is what my grandfather used to have." According to Sonya, the wizard and her grandfather were two different entities. She described the wizard as an "it. It just stands there, and doesn't say anything.. .just stays in the forest, in this beautiful forest. It's a forest, but it's a magical place, it's not real. It's a green forest, part of it is but most of it is crystal and glass. And the wizard stands by this tree. It's a willow. I always like willows. They are beautiful. They weep. They are beautiful. They are so gentle. That's what I like about them. They are gentle and they are soft and they make the most beautiful sound in the wind." We agreed to do some guided imagery to go to the wizard. Sonya found the wizard by a tree, on the right side of her chest. Then she determined that the wizard was actually outside of her body. Sonya said she did not trust the wizard. She felt a tightness in her forehead. She felt she was supposed to surrender to him but she could not. She said shakily, "I don't trust that I am not going to get fat.. .if I let go.. .1 have to be willing to." Sonya felt she would have to get fat in order to heal because she "needed to be taught a lesson, or punished in that she wouldn't be loved if she were fat". She felt she needed to let go of her vanity and her ego which would happen if she became fat. She began talking about the darkness on the inside. I asked her what it felt like to be fat on the inside and she replied contemptuously, "Dirty, dirty and unclean and lower class. Stupid." Sonya reported the wizard was calling her to join him but she felt afraid and feared it was a trick. She was convinced that if she went near him, he would turn into something very evil. She spoke with reverence, yearning, and distress, "It's a super wizard in all light and I see him from all darkness. The forest is bright, but I am all dark. It's like everything I want, he is. But I can't, I am too afraid to trust. I don't think I deserve it. I think I am bad. I think I am stupid. I am a failure. I am not successful at anything I do. I am unhappy. It is like why would he care?" 70 Sonya talked about how much pain she felt and that, in a way, the wizard was "mocking" her. Suddenly, she began talking about her grandfather and how he beat her brother everyday for years, "and I would wanna take my brother and just hug him and I can't cause I feel I shoulda done something. The wizard tried to leave me then and I wanted him to stay. So he did and he has never gone since. He's just anchored, just waiting. Just waiting. I don't know what he is waiting for." Sonya reflected on her experience after we finished the exercise, "I am feeling sadness. I just wanna let it go, go forward...surrender..just let God run my life.. .turn it over. And it's not there and I am so tired. And I want it so bad, I am not trying to fight it I just wanna let go. I am tired of exercising, I am tired of compulsive eating, I am tired of spitting out my food.. .1 am tired of the whole process and my body just won't let go and I am exhausted from trying to and trying to turn it over. I am so tired of hating my body and going up and down and up and down. I am just exhausted and it just will not let go.. .too much fear." Therapist's log. session 1. Sonya vacillated between being very talkative and dead quiet. Sonya's voice was sometimes raw and guttural, sometimes breathy and girlish. She sat slumped, and seemingly melted into her chair as though she wished it would swallow her up when I was not looking. She rarely looked me in the eye. Sonya was very uncomfortable with the drawing component of our work but she gravitated very naturally, and quickly, to the guided imagery exercise. While in the midst of it, she seemed to juxtapose very different images. The forest, for example, was both a place of greenery, aliveness, and beautiful light. But it was also dark, and filled with crystal. I wondered about Woodman's (1982) documentation of bulimics seeing themselves in glass coffins, in view of, but sealed off from, life. The wizard was also confusing, he appeared to symbolize both good and evil. He was good from far away, terrifying if approached. And what was the connection between her grandfather and the wizard? 71 During the imagery exercise, Sonya seemed to slightly dissociate from time to time. But it may have simply been that her ability to visualize was so rich that it took her a while to take in all that was before her. Figure S1.1. "Poppa": Poppa was the name Sonya used for her grandfather whom she associated with the Christmas tree depicted in the drawing. The Christmas tree, and the roots, were largely red, not green. The drawing was filled with stars, black clouds, a red arrow, and a cluster of purple squiggles that resembled a penis. Figure S1.2. "My Kids": Sonya used bright colours and had drawn the both children with open arms and smiles on their faces. She drew her niece with hands, and her nephew without hands. Neither child was standing on a groundline. She had written the words, "performer" and "loner" above their respective heads. Figure S1.3. "Vacationland": Sonya drew a smiling sun along with a blue boy and a red girl holding hands next to a purple (spiritual?) sail boat, all floating above the water. In the upper hand corner of the page, she drew a white cloud with a drop from the cloud in the water below. Figure S1.4. "How the world sees me": Sonya drew the entire drawing using an orange/red crayon. She wrote the words "weird, "out there", "wild", and "wildebeest" (sic) on the left hand side of the paper. She drew herself with a smiling face and no hands, breasts, or groundline, with a thick line drawn across her waist. Figure S1.5. "What I see when I look in the mirror": Sonya drew the whole figure in purple with a frowning face and a tear on her right cheek. She gave herself three chins, a wide face and a very wide body below her waist. She did not draw fingers, feet, or a groundline. Figure S1.6. "My Inner Healer": Sonya depicted her wizard in the center of the page with a brown body that looked like a tree trunk firmed rooted into the ground. His beard, 72 face, and arms were rendered in blue. He held a large staff in his right hand. He had no fingers, or feet, but he did have ears and wore almost a frightening smile on his face. He was adorned with a conical, blue and green, hat. He stood beside a large willow tree drawn in brown and green. Session 2, November 6. Sonya brought a beeper from work and left it turned on during the session. I did not comment. She began by talking about how she got along better with men, or women who were like men. She talked about how she thought she dressed like a man but was, in fact, told by quite a feminine woman at work that she was very feminine. Sonya chuckled, "I was surprised. Cause they call me the biker chick at work. Everybody calls me that. Cause I have a real toughness about me, a defense. And I am tough and smart. And I love male things: I love motorcycles, I love working on cars, and I love sports. I go to games. I sit with the guys, I talk with them." I asked Sonya to draw a picture (Figure S2.1) of the male and female parts of her. She offered, "For the masculine, I could draw a motorcycle. And for the feminine, I don't know. I think the femininity is my strength and my compassion for kids and people." Sonya stopped drawing and began crying saying she felt too much shame and pain around drawing. She talked about being terrified of getting in touch with what's inside. "Cause I am afraid that is all there is. That all there is just pain and pain and more pain and that it will take forever to heal it. Cause that's all I have ever felt and I am just sick and tired of feeling pain and sadness and wanting to die. I'd rather stay in denial so I don't have to go through this. It's not worth it anymore to me so that I don't have to be hurt. To feel like dying all the time. And then to hurt my friends because I am so fucked up because they are so scared for me. It's like I am not even a person. It's like...I just don't want to be here anymore. This is all it has been. Is this. For years and years and years. Just a constant sadness. The constant depression. The anger. The fears the phobias. It's like I don't have a life. I have nothing. I don't believe that there is a power that cares about me or that there's a power that wants me well. It's like what I said about the wizard, I just can't 73 because if I go over it's all gonna be a big joke and it will be worse. It could stay forever. I could lose my friends. I could get really, really fat. I could, lots of things. That's what I see. I don't see happiness. I don't see good things. I don't think it's possible for someone like me. My big joke, because I am such a joke is that I am just a fake, I am just a big fake. My joke is because I can't travel or go away or do anything normal. Because I am not normal at all! Even my doctor said to me that I am a scientific phenomenon because everything I get is either backwards or weird or symptoms that no one has even had before. I feel like a freak anyway. So that just fits." She started talking about how men loved her and had crushes on her but did not go out with her; about how she would always end up alone because "there's nobody who can put up with me for long" because "I am not normal, I can't travel, I can't go in elevators, I am crazy around food, I am angry all the time. Spiteful, miserable, depressed. Nobody... .1 don't want anybody in my life." She talked about suicide, and not being afraid to die anymore, and that death would be freedom. Sonya outlined methods by which she might kill herself, explaining that she had been depressed since she was four. "I always felt I was weird and different and odd. I mean, at four I thought I was a failure and wanted to die." She talked about wanting to be a boy, "Oh, well. The way I look at it, men don't spend their LIVES, like I have, wanting to be in a relationship. They get to do, they do things. They do stuff. They don't.., girls sit around and wait for the fuckin' phone to ring to fall in love. Guys get to get out there and they have adventure and do things. And most guys I know on their resumes they have all these sports and all these activities they do. Women do nothing: reading, and writing and all this bullshit. Men do.. .everything", she sighed wistfully. "Men go out and do things.. .there's adventure in their lives. There's power in what they do. Women sit around and wait for the phone to ring. Men are always in control. It's funny. I love women. I just love women. I just find men more exciting and more fun. There's just so many more things they do. I don't like men in general. When it comes to sex, I hate them. I HATE THEM. 74 Absolutely hate them. But with, men there's just so much.. .you are born a man, you are born into power. We, as women, we have to be fucking secretaries, and bimbos and run around with our tits hangin' out on TV to be appreciated. I see it in my business all the time. Goofy guys can get great parts but the women have to be great lookin' or else they are wenches or hags. It's constant. Constant!" We finished by talking about the movie, "The Wizard of Oz". Sonya loved it. She owned a copy of it on tape. She loved the message, "staying in your own backyard which means staying inside of yourself... finding it within" As we talked about something positive, Sonya's demeanor changed. She began saying she felt scared, undeserving, and wanted to die. We talked about loving ourselves. I set up a contract with her regarding her safety over the weekend. She agreed not to try to kill herself. Therapist's log, session 2. Sonya had called the day before our scheduled appointment to say that she could not make the appointment and that she had lost her job, and her boyfriend, and did not want to live. At the beginning of the conversation she had said she could not make a rescheduled appointment on the 6th. By the end of the conversation she felt that she could. I continued to ponder the meaning of the wizard imagery. I was intrigued to hear that "The Wizard of Oz" was Sonya's favorite film. I reflected on the possible parallels between the movie plot wherein the wizard did not turn out to be what everyone thought him to be originally and the possible hidden nature of Sonya's wizard in her imagery. Figure S2.1. "Male and Female": Sonya began to try to draw a black motorcycle but she faltered and felt unable to continue because of the tremendous shame she felt when she attempted to draw. Telephone debriefing, week one. This week Sonya said she had discovered that she still had a lot of anger toward people who had hurt her in her childhood and that anger is wrecking havoc in her adult life. She really wanted to get that anger out! Sonya was also 75 increasingly convinced that OA had not helped her. She wanted to feel like she had direction in her life; she felt tired of feeling directionless. She talked about her discovery this week of how much power she had given to men in an attempt to define her value; she wanted to change that. November 8th, Sonya phone call. Sonya phoned to say she could not make session as planned on Nov 9th so we rebooked for the 10th. She was crying hysterically because she had seen her boyfriend, with whom she had broken up four days prior, two seats in front of her at an AA meeting "kissing and fondling a new woman". Sonya screamed, "if I had pills right now, I'd kill myself". To that end, we renegotiated our contract and she agreed not to harm herself, at least not until we had seen each other again for another session. Session 3. November 10. Sonya arrived complaining bitterly about the cold and her job. Even so, she appeared to be in a more elevated mood. We talked about the vulnerability and lack of appreciation she felt around her job. She said she felt very alone. Sonya explained that her sister would not help her financially and did not want Sonya to see the kids while she was in an upset state, "So I just have nowhere to go.. .1 am always the loser, always fucked up". Sonya talked about how disgusting and humiliating poverty was: "I grew up in poverty. I grew up with a mother on welfare with us going hungry living in filthy old dumps. Having to live with men that I hated because she was so broke. Having her date men so that we could eat and it's disgusting. And it's where I am: poverty and no control. I am tired of feeling helpless and powerless." I observed that Sonya had been playing with a cross she was wearing around her neck when she talked about powerlessness. She said contemptuously, "don't know why I wear it. I guess cause I wanna believe in God, but I don't. I think God hates me. I don't think God gives a shit if I live or die. I don't know what God is. If there is such a thing." I 76 attempted to clarify, "So even the higher power has abandoned you." She corrected me, "I don't think the higher power has ever been there. Not for me. Once in a while things show up and I know there's something there. ..but I don't think it likes me. Not at all." I asked Sonya to put her pain inside a small box for a bit and to consider what life would be like if she could have whatever she wanted. Sonya began the imagery exercise and smiled, "that I would be happy, I wouldn't want to be dead everyday.. .just not to hate myself." Sonya paused and reported that she felt nothing but sadness. I asked her to go with the sadness. It showed up behind her eyes....tears...an ocean of tears behind her eyes. She found herself treading water in the ocean of tears. Sonya cried she wanted to stop struggling. I encouraged her to stop struggling, to stop treading water. Sonya retorted that nothing would change and that she was afraid she was going to drown. I said, then drown. She said she was afraid if she did she would die, or gain 300 pounds. She qualified, "If I let go of control I will die because God doesn't care. If I let go of control I will eat until I blow up and I will be 300 pounds and I will be dead. I'll never be able to stop eating because I can't. If I let go of food, God won't take care of me and I will die." We decided to evaporate the ocean. Sonya then visualized herself lying in the sun on a beach. She reported that the wizard had appeared, that he had touched her hair, and suddenly she felt six years old. I asked what the touch meant. She said "To tell me he knew.. .that I am tired and I don't wanna do this. He knows I am just weary. He knows everything but he won't talk. He knows everything. He needs my trust. I am too scared.. ....all of a sudden^oohhhh, how weird.. .it's really bright, behind my eyes.. .it's really bright. He knows I wanna let go but I am afraid. He knows everything.. .he is sort of like what I am like with little kids". Interestingly, although the wizard was kind to the six year old, Sonya felt he did not like the adult because she "was bad". She refused to reach out to his beckoning hand because he would turn into "a scary creature with withered horns, like the devil". The 77 wizard was, in effect, two people: with the six year old he was "Jesus-like" in the light; with her as an adult in the darkness, he was "devil-like". As we came out of the exercise, Sonya commented that, "It's weird cause I kept calling Jesus all last night, and I hate that word... .it's too Christian for me". She was quite dizzy for a long time after finishing the exercise. I finally grabbed her hands and stood her up to help her become aware of her body again and then she was fine. Therapist's log, session 3. I was intrigued by how often Sonya referred to God. And yet, she felt that God "hated her". She admitted to attempting to engage in conversations with Jesus, and yet, she was convinced she would not be relieved of her pain even if she were able to actually do so. Session 4, November 12.  Sonya began by stating flatly that she did not want to be at the session. She elaborated, "I am really shut down today. I need to protect myself'. We discussed the comfort she found in shutting down. She talked about feeling very depressed and unhappy. I asked her about the conversation with Jesus the other night, what did she want? She said, "I wanted to die. Without pain. I wanted to just go. I wanted it to be over. I couldn't take the suffering anymore. If you care about me then you'll let me die. I wanna have the courage to do it because I am tired. I don't see any hope. Nothing changes. I just keep calling and calling like I have been doing for years. There is no God, I just don't believe it anymore. Nothing listens." I remind her of the fleeting feelings of the presence of God that she had told me about and asked what that was like when it occurred. She replied, "It's like a knowingness...it just sort of bursts through your whole body." I asked if her eating was effected in any way when she felt these fleeting feelings. She replied that she almost always ate because she felt the "hollowness in an even more accentuated way" after she had felt a knowingness. After experiencing the sense of God, it was much worse in that she felt she knew what she was missing. She bemoaned, "It's not life. I don't live. I just survive day to 78 day. I am alive. I am alive physically. Everything else is dead. Dead, dead, dead. I have no spirit. I have nothing. Everything about me is dead.. .it's all dead. Everything inside is dead. I have no hope. I have nothing. I have no hope. I am too tired of trying to find it." We began to discuss a time in Sonya's life when she did feel alive. She identified herself a four years old. I asked her to draw something from that frame of mind (Figure S4.1). As she drew she uncovered that she "never felt safe or cared for. I was always unique. I was always the one at school who was the black sheep. People still look at me as a really unusual person. .1 always wanted to be like everyone else...never was.. .in society if you are different...artists that struggle and struggle, people that are so gifted are looked at like freak shows." Sonya began to sob, "All I care about in my life is making sure that people that feel different don't feel different. If that's all I could do in my life, that's what I want to do. I just don't want people who are different to feel bad about it...I teach, free, work for a disabled group. I got them tickets to a Broadway show. I just love doing things like that.. .1 really wanted them to go.. .people never pay attention to them. It's want should be done.. .the way I look at the world. And then I got the disabled group to meet the Broadway show cast. The whole thing was worth it just to see that. And that is what makes me happy." Therapist's log, session 4. I felt Sonya's statements about being alive physically but dead in every other way were very powerful. I was struck by the beauty of Sonya's heart and her utter inability to recognize any of that beauty within herself. I wondered how this related to her sense of Godlessness. Her only real joy appeared to come from helping others, from forgetting about herself and being truly altruistic. Figure S4.1. "Yellow": Sonya drew the entire image in a bright, lemon yellow. It consisted of a centered, thick horizontal line with another yellow line and a ball hovering above it. 79 Telephone debriefing, week two. Sonya reported continued binging. She also said she was not remembering the work we were doing in sessions. She still felt a strong urge to kill herself and felt that, "if God gave a shit, he would help me do it." Sonya lamented she was getting fatter and yet could not find. She underscored how "terrified" of food she felt all the time. Session 5, November 16. Sonya arrived with a big mug of coffee. She was in a good mood because she and her boyfriend, Jason, had gotten back together. I asked Sonya to draw happiness. She could not but agreed to a guided imagery exercise. She gravitated to her third eye (forehead area) and then dropping into a forest in her stomach which was comprised of a sea of Christmas trees. Sonya described the forest as pleasingly dark and cool, comfortable, quiet, and still "the trees are very peaceful and very serene, they are content. There is something about trees, like a contented, happy person... they give off so much. Just being, sort of like the wizard. I just like touching the trees, they are like the wizard, they don't say anything, they don't say anything they just know, they are waiting for me". I asked Sonya about allowing herself to feel happy in the forest, she replied furtively, "I think I am too afraid to feel good because it will be taken away...I am afraid to think I will get well because I don't want to be disappointed anymore...I am afraid to say things are okay today because what if they aren't tomorrow. I don't trust it because it will be taken away... everything will be taken away from me just like..." Sonya paused and began to cry, "I had a daddy...and he went away." Sonya regrouped herself and reported that she had reached out to touch one of the trees. Suddenly, it began growing, "a Paul Bunyan tree.. .it's so big it's overwhelming.. .it's getting scary.. .it's getting mean. It's me, the tree is me!!! It's the grandiose performance tree. It's filled with lies, garbage, ego and fear, it's so huge because there is so much of it there... .full of crap. It's definitely me. I don't trust it." I asked about the other trees in the 80 forest. Sonya described them as covered with jewels. I asked if Sonya could cut the big tree down so that the other trees might receive more sunlight. As she contemplated this idea, she suddenly announced that the wizard was standing right beside her, wanting to help her in her task, "He has an axe too. He is very very small, even compared to me. He is radiating light. The tree is so evil. It feels so evil. And it is daring me to touch it. Very evil. And it so big." Suddenly the tree became red. Then Sonya felt her grandfather was present. The tree was huge and solid inside. Sonya was not convinced the magic axe she had would work. Then Sonya took pity on the tree. She felt that the tree was very sad. She found herself not wanting to hurt it or destroy it. She discovered she had respect and love for it at some level. I asked Sonya to put the axe down and to hug the tree, to pay attention to it, and to give it a kiss. I spoke, "I love you tree, I know you were abandoned, and left alone and no one was there for you. I feel your sadness and your loneliness. I understand why you are filled with anger and meanness because no one paid attention to you. Well I am here to love you." Sonya's voice cut through the room, "My God, it's shrinking.. .oh God oh God, my whole body feels so weird". Sonya began to hyperventilate and her voice sounded panicky and incredulous, "It's like someone opens a valve and let all the air out of it...it shrank.. .now there's this little thing that died.. .1 feel so sorry.. .it's like I killed something". I assured Sonya, "No, you gave it lots of love.., as soon as it got the love, it was able to take on a different form, the air, the water, the stars.. .it's transformed into love.. .you gave it love". Sonya began laughing, "it's a little tiny Christmas tree on a huge stump". She wanted to pick up the tree and hug it and keep it with her. She did so. She felt it would grow again. Therapist's log, session 5. I was continually surprised by Sonya's mercurial moods. This session was no exception. I found I had to be prepared to move very quickly with Sonya. Her mood fluctuations were also reflected in the extreme differences in good and evil in her imagery. Both the wizard and the tree were good and evil, they both had a 81 "knowingness", neither one spoke and yet had a strong consciousness about which she was acutely aware. I was also interested that Sonya felt so much discomfort with white light whereas she felt fine with the blackness; it was home to her. Session 6, November 19.  Sonya arrived, chewing gum, and announced immediately that she had broken up again with her boyfriend which had caused a "complete nervous breakdown last night. Men don't respect me. Men look at me and I am just a fuck. It's all tied up in the body image thing, the looking good thing." Sonya began talking about how she was defending her illness, "I keep saying I have been working real hard for years. I am working hard at fighting everything that is coming my way. I know I am wrong but I am not fucking going to tell you that. I have worked very well at not getting well. I have tried hard to get well but I have not been willing to do anything that anybody says." I asked Sonya if she knew of any good things about not getting well. Without hesitation she responded, "It shows everybody that I am right. That I am the exception. It gets lots of attention." Sonya paused and then reflected some more, "I don't even know if I wanna be well. It's too uncomfortable for me. It's too hard to stay happy. I am so one way. I don't know if I'll ever be able to break out. It's too much work. I'd like to do something in work besides trying to find out what is wrong with me. It's not that I like it, it's just that it's easier to stay there. It's been so much work in OA and therapy and I don't feel better. I might as well stay here. I fight everything." I enquired of Sonya as to what she felt might have been the missing ingredient in her ability to benefit from therapy. Immediately she replied, "willingness. I don't really understand why I do anything. I am so shut down.. .1 heard a wonderful saying that pain is only resistance." I asked Sonya if she sensed there was anything beyond the resistance. She replied quietly, "I don't know if there is anything else. I only know where the anger and frustration is. I am so frustrated it's like there's this huge ego that won't let go. And I pray and I pray and it won't let go. I am tired of the lies and the whole game I play. The hurt little girl. The hurt little victim. I play hurt and I get attention." 82 Sonya draw a picture of her ego (Figure S6.1). As she drew she confided, "My ego is so huge. It's black. I love the colour, the non-colour black. I am so attracted to it instantly. Everything inside of me is black. Everything is buried. It's all black, just hollow black. I can't hear.. .whenever I go inside, I can see the forest, but it's all blackness... my head, stomach, heart.. .1 can only see emptiness and blackness. I don't feel things, I think them. It is almost impossible for me to feel anything." Sonya talked about what it would mean to actually feel, "It's like if I give up my ego I am lost. I have lost the war. It's like do you want to be right or do you want to be happy. I have to be right. That means somebody will have one up on me God...God will have one up on me. If I let go of all my bullshit, anger, negativity rage...I lose my bitch. It is amazing how many men want to be around me and I am a bitch to them. I have that power." I asked Sonya if we could not talk with the bitch, empower the bitch? She sighed, "I think the bitch is wrong. that's why I give my power away to men.. .1 am not smart enough." I asked Sonya about the relationship between ego and food. "I don't know what it is...control. We are so outta control, we are going to control anything we can. Control food." I asked how she felt after purging. I think with my ego, I need to stay sick to feed my ego. If I surrender then my ego loses.. .(to God).. .and then I have lost. If I lose, then I am lost" she stated emphatically, tearing running down her cheeks, "who am I if I am not the bitch. Who am I if I am not the slut? Who am I if I am not the mouthy... I don't know who I am and I am too scared to let go...nobody would know me if I wasn't the tough, sleazy little bitch. Bad is what I do. What I let men do to me. I give sex to get love all the time. There's a lot of men I have slept with. I have a reputation for that. I am my looks and that's it. There's nothing else inside of there.. .I'm a sick fucked up person.. so I have got to rely on something, so if I don't get thin, I am nothing." I asked Sonya about the opposite of sick and screwed up. She smiled, and said resolutely, "Joyous and free and peaceful". But she quickly snapped back to describing her relationship with, and seemingly talking to, her 83 ego, "hate, it has complete control over me. I am not going to let you have all the good things. I am not going to let you be happy.. .have who you want in your life." Sonya snarled, "My ego loves to make me eat.. .it's like Ha HA...everytime I feel positive. I eat something and try not to be afraid of this...but it says yes you are. You are going to get fat...you are going to get fat. And then I have to spit everything out. And if you get fat then you are not attractive therefore...you'll be alone, and afraid." I commented to Sonya that her ego seemed to get her coming and going: if she was slim, she was promiscuous and ashamed; if she was fat, she was alone. Sonya agreed wholeheartedly, "Uh huh... it has complete control and it lies to me all the time... .that I believe. It's the ego.. .it's the evil in me. It's the Satan.. .it's wants to kill me, it wants to keep me so unhappy so that the God part will not come through. It won't let go, it's afraid that if it does it will die." I asked Sonya where the God part was in her body. She replied that it was in her heart. She began to draw her heart (Figure S6.1). She described the knowingness as being in her stomach, "it's strong like a rock.. .the blackness is everywhere around this". We agreed to attempt an imagery exercise. I asked Sonya to go inside into her heart to visit with the God. She was unable to do this. She drew an absolute blank. We completed the exercise and I complimented her on her good defenses, taking care of herself and knowing when it was appropriate to look into herself. Therapist's log, session 6. I found Sonya's energy level to be incongruous. Sonya's on again, off again relationship with her boyfriend felt like an allegory for her own battle of relationship with self. She was the one breaking up and getting back together. Her boyfriend wanted to be there for her but she felt uncomfortable accepting her support and affection, particularly since his care for her did not, as was usually the case with men, revolve around sex. 84 As we worked on the guided imagery work, I felt as though Sonya seemed aware of her inherent goodness but was only able to access it sporadically; some days she could, others days it felt virtually impossible. Figure S6.1. "The Heart": Interestingly, the heart was hollow. The downward right- pointing arrow may have had some phallic symbolism. The red may have represented anger, passion, sexuality? Her depiction of the black ego, was solid, and also pointing down to the right. It was very similar to the shape of a purple object she drew in one of the drawings in the first session. I did not have any sense of the significance of the protrusion on the left side of the page. Telephone debriefing, week three. Sonya reported her binging had been as bad as ever. She stated she did not want to come to therapy anymore. She had been pounding her thighs till they were badly bruised. She said she has been "begging God for surrender". She felt the situation was "not going to change.. .only going to get worse. There is no God." Sonya began talking about her boyfriend again at which point I asked her if she felt her boyfriend would be willing to join us for one session. She asked him, he agreed. Session 7, November 24 (Sonya and her boyfriend, Jason). Jason was a recovered alcoholic who harbored no illusions about the difficulty of attempting to change one's way of being in life. We began the session by discussing safety issues. After which time both agreed to play in a role reversal exercise. I asked each to begin by assuming the posture of the other and taking a moment to "be" that other person. Jason began as Sonya by saying that he wanted to die, that the compulsion to eat was with him all the time, that he felt fat all the time, and chastising Sonya (as Jason) for still hanging around. He finished by stating that he had friends who had recovered so why couldn't he? Why couldn't he just let go? Sonya responded as Jason with clarifying questions about simply accepting where he was at the moment. She volunteered kindly, "If you are this weight for today then that is what you are supposed to be. I care about you. Why are you trying to make me go away. 85 Why do you think you have it harder than anybody else? Why do you always want more? What is it you don't know? What are you supposed to know? You have not accepted where you are, you would rather fight it." Sonya stopped for a moment, and squirmed uncomfortably in her chair. She continued, adopting a different tactic, "Can I get you to believe that what is going on in your head is a lie.. .it's just a mechanical tool.. .and when the voice come back you can say that... my dad told me I was nothing when I was growing up and I don't believe that anymore.. .can you just try to believe that what I said was true?" Jason remained quiet, pensive. Sonya persevered, "just for right now. Not for tomorrow but right now. Can you maybe see that if everyone else around you feels and sees something differently that maybe what you are seeing isn't the truth." Jason finally responded by trying to divert Sonya's attention asking if she would like anything to eat, to drink, or would she like to watch the Wizard of Oz, or have her feet massaged? Sonya snorted and smiled recognizing her own tactics. We completed the exercise. Sonya reflected on her experience as Jason trying to reach out to Sonya. She stated that it was very frustrating especially since she genuinely cared. Jason declared that he did not feel willing to accept Sonya's efforts, "I had to defend my position. I would have to give up. Then I would be out on a limb. I wouldn't know who to be. I have been this my whole life. I don't really look beyond the fact that I am not willing to give it up. I am not even looking far enough to feel the fear. I am beginning to see that it is just a position I hold about myself. Before that. I was who I was. You can't imagine how much energy it has taken to defend this against the word. Jason's reaching out doesn't mean anything. It is just noise...I have to defend who I am, it doesn't allow for it." Jason paused and attempted to read Sonya's expression. Sonya appeared deep in thought. Sonya continued with her experience as Jason, "It's not just frustration. It's feeling really pushed away and cut off and really undone... .thankless. It's like trying to climb up a 86 sheer wall. You know what you are saying is right, and it would help. It's like a diabetic saying, 'no I don't need my insulin'.., reaching a victim." I took a moment to ask Sonya where she went in herself to find Jason's character. She answered the part that had, "unconditional caring for people. There's a lot less energy put into than being angry. It's just a really open place than being shut down. It's much more open. There's just a lot of acceptance. There's no conditional terms. It was just a lot easier.. .1 wasn't so fearful. It's uncomfortable for me and so of course I shut down a lot of what it felt like. It was a lot more powerful. Not in an ego powerful. Just to feel a lot more sense of who you are without the fear and the anger. It felt much more warm." I asked Sonya what it might be like to feel like she felt as Jason all the time. She replied immediately, "I am not comfortable saying I am well. I would rather say I am not.. .it's much easier." I then asked Sonya if she had any questions for Jason regarding what it felt like to be her for a few moments. Sonya asked Jason if he now understood, "the fear of not being able to get out of where she is.. the fear of being stuck...does it make sense how much I hate it but how much I hold onto it?" Jason mused that he was so determined to be right that he wasn't even feeling the feelings as much as he wanted to be right. Sonya clarified, "So what I try to do is make other people wrong. And resist. I am always going back to people and saying I am sorry. I hurt people." Jason volunteered, "I don't think you hurt people. You hurt yourself." I asked Jason how he felt to hear 'I'm sorry' all the time. But before he could answer, Sonya said, "It's a victim thing to do...disempowering. Like the wounded puppy syndrome. I always think I have done something wrong. I always have a sense that I am in the way. I will inconvenience myself to the utmost before I will inconvenience other people." I asked Jason if he would like to give Sonya a gift the next time she gets into a place of being unable to accept love or support from anyone else. He smiled and responded immediately, "a statue of her hugging herself". Sonya smiled knowingly. 87 Therapist's log, session 7. The role reversal proved to be very instructive. Jason was an exceptional mirror of Sonya's behavior. She was stunned into seeing, and feeling, from a different perspective. She was given a safe method by which she could test out and experience what it felt like to feel more positive in the world. I felt Jason's 'gift' to Sonya was brilliant. I felt that she was attempting to unite her dark and her light, to allow her spirit to be born into recognition within her. This gift embodied that effort so elegantly. This session felt like a real turning point in Sonya's ability to move toward wellness. Session 8, November 26. Sonya arrived sparkly eyed and buoyant. She seemed a different person. We talked about the last session. I read to her what she had said when she was playing Jason. We talked about the experience of being in a place of comfort within one's self. We talked about the difference in energy required. Sonya went on to describe how something had changed for her. She explained, "I am feeling so positive and nothing has changed. I still don't have a car, a job, I am still overweight. I hate my hair. I am still eating too much. I feel very unattractive these days. I feel fat. I don't feel pretty at all. I want to get to the place that I am still binging over and still compulsing over. Yes, it's a spiritual illness. There's a reason that I am still binging. I am still eating a lot and I can't put things down and I am eating most of the time." Sonya began talking about acceptance; that that is the key to recovery. Sonya talked about surrendering her bulimia. She mused, "I do deprive myself constantly of food. I am frightened of it. Terrified of it. There is no question it has complete power over me. I am powerless because it has complete control over me all the time. I am always thinking about how to get away from it. What not to eat. Not what to eat but what not to eat." We talked about giving to oneself in other ways than just food. She talked about "buying bubble bath stuff.. .bathroom stuff, incense, loofa sponges.. .bathroom stuff, and CDs...that's what I buy for myself". 88 Therapist's log, session 8. A fundamental transformation had taken place in Sonya. I felt she exuded a different presence in the room. Sonya felt to me like someone who had had a near-death experience and now appreciated life in a different way. I wondered about the interesting challenge for Sonya in how she would say goodbye to her old self and her old behavior. I was spellbound with how Sonya might continue to transform in light of her experience with the role reversal. How would she continue to develop her inner core? How would she grieve, and distance from, the old, black, hollow carcass that she thought was her being and move into her true, multi-coloured self? Telephone debriefing, week four.  I phoned Sonya a few times but she was not available. Session 9, November 30. We started by talking about Sonya's money situation, her continuous feelings of poverty, and how she felt her bosses abused her desperation situation by habitually underpaying her. Sonya also declared that her boyfriend, Jason, was starting to see another woman but that she felt "okay around that." I asked Sonya about the eating. She sighed, "one moment of rejection and I am in the kitchen because I can't stand the pain of rejection". She talked about a black demon in her solar plexus that made her eat. I asked her to draw the black demon (Figure S9.1). As she drew she said, "it's sort of satanic, from all different movies.. .it's so big, such a demonic evil, it just takes over my mind and my control". I asked Sonya if we could undertake a guided imagery exercise. She agreed but warned she had never talked with it before. I asked her what protection she would need in order to be able to go in and talk with the demon. She said she would need a white light like the wizard had. She explained the demon was like Gollum (a dangerous yet pitiful character from J. R. Tollcien's, Lord of the Rings trilogy). As Sonya moved into the exercise she exclaimed, "something has clicked with the powerlessness.. .1 feel completely powerless over the creature... the same way I feel about 89 the food.. .they are connected. I am just wondering if that creature isn't the food." Sonya had focused her attention on her third eye. She stated, "there is an archway that is all white and then it is all black. I am not afraid of the darkness. I hate it but I feel sad for it. I want it to stop but I don't know what it is. I have hated it so much. I feel like it is not a part of me that is something else. It doesn't belong to me. It is another person inside of me. I haven't amalgamated with the blackness. It is another person controlling my life. I have to merge with it and be with it and love it. But I hate the blackness, I hate the blackness so much. It makes me eat. I know it does." Then she was hugging a big black ball. She determined, "it's about trust. It's all about trust. I don't trust it. It gets bigger and bigger." The blackness was like a vapor. It had light edges and pulsated. There was no image. Then she had an image of a purple heart in her third eye. And she flashed on the feeling that talking to the blackness was like talking to a child, "the blackness is me when I am about 5." Sonya felt really angry at the child and the child was mad at Sonya. Sonya felt the child was making her eat for "safety and protection". Both Sonya and the child were quite diffident. Together they stomped and screamed for a while. Sonya paused to smile and said, "I am really glad she came!!!" Therapist's log, session 9.  I interpreted Sonya's buoyancy surrounding her boyfriend's move with trepidation. I was not at all convinced that she would not plummet into the emotional depths at any moment. All the same, her spirits were those of a different person compared to a week prior to our session with Jason. I felt that Sonya was at a very delicate stage of transition from being in total darkness to allowing both dark and light in her life. I felt almost afraid to move for fear of breaking the spell. I found myself pondering her continual use of her third eye as a conduit, or clearing house for the emotions she eventually felt in the rest of her body. Figure S9.1. "Little Black Devil": This creature appeared childlike, with a big belly, big tail, arms outstretched, left leg obstructed, a diagonal line from upper left to lower right 90 with hook at end, a really long neck, and a black body with a white face with big pointy ears. It was both amusing and somewhat sinister looking. Session 10, December 3. Sonya arrived still in a good mood. I marvelled at the change. She talked about helping two OA people through providing them with support and positive encouragement. We talked about her food consumption. Sonya admitted she was still binging but was spitting much less. She observed, "I don't really want to think about food anymore. I want that to be the most unimportant part of my life because I want to live my life now. I don't want that part of it anymore. I am so afraid of food still that I tend to eat very similar things every day. It's so boring. I don't want it anymore. But I still think if I let go God is going to make me fat." We talked about the nature of personal transformations. We talked about having patience and not being in a big hurry. I asked about the wizard. She felt that he was still in the forest. She speculated that he represented someone in her life, There is a big piece missing that I haven't gotten yet and I am really aware of that.., the spiritual shit that has not connected yet." I asked if it has to do with the wizard. She mused, "part of it does. There's just a feeling that the belief.. .it's just empty. I know there's a God. There's something but I don't' know what it is but I keep asking for it. I haven't got that connection, there is something not connecting. I still don't think it's God doing this. I still think sometimes it's me. But I am not a higher power." We spent a good portion of the session discussing her concern over her agoraphobia and how desperate she felt about overcoming that impasse in her ability to move through the world. She expressed a desire to visit some relatives out of town at Christmas and fretted over whether she could recover in time. Therapist's Log, Session 10.  I was interested to see how quickly Sonya used any strength she had found within herself to give over to helping others right away. She immediately used her new found strength to help her fellow OA friends. 91 I was also intrigued that Sonya had moved so quickly into talking about her agoraphobia the moment things appeared even slightly better with her eating disorder. It was as though she needed to hang on to some major setback so that life would not appear too good and therefore be in danger of figuratively exploding in her face. This awareness may also lead to a potentially stronger therapeutic bond forged through the possibility of the bulimic client feeling a more profound sense of having been deeply heard and understood; embraced and appreciated rather than alone and alienated. Telephone debriefing, week five. In spite of several attempts, Sonya was not available. Session 11. December 7.  Sonya brought me a present (some writing paper and a wizard pin). I accepted on the condition that we share the pin. She smiled and agreed. She talked about how she had started to binge last night but had decided to stop midway through and feel her emotions instead of blocking them out. She said she was able to stay with them. They were feelings of loneliness and abandonment caused, in part, by splitting with Jason. Sonya also brought up an incident which had occurred on the weekend wherein she was inappropriately approached sexually by a pseudo-relative. She had stood up for herself. Further, she had called him the next day and had really chewed him out. Sonya was proud of herself that she had been very firm and strong and comfortable with her boundaries. She continued that she had had a wonderful day, "a day of answers coming to me as quickly as I asks the questions". We discussed the continued pressure she felt regarding getting over her agoraphobia before Christmas. I asked why she was putting all this pressure on herself. She was not clear on that. Sonya then volunteered that she had moved the purple wizard from outside herself into her body. She said she had felt, "a high, bright light. Then it shifted...a rush through me. But I know I am not there. It's changed a lot but I am not ready to pack my bags." We 92 talked about how much movement has happened in the last couple of weeks. She stated, "it feels like a whole pile of rocks. And you move one rock and the rest tumble down. That's what the last two weeks have been like. It's like a clearing. The damn just burst and it is pouring out. So many transformations. But I have a real difficult time believing. That's what it is ...I don't trust.., travel. That is my life line dream. I have a hard time believing that it could ever change because that is something I want more that anything. I think I would sacrifice my eating disorder... I'll keep that, just let me travel. I feel very powerless over it. I want to rush this. I don't know if it's resentment. There's still something that won't let me go. I don't want to be a prisoner of it anymore. I am so tired of living here." Sonya suddenly noted that it had occurred to her last night that she looked me in the eye now, "I used to look at your feet." She stated that she did not feel she had "to win" with me. Then she began talking about her sister, about how jealous she was of her sister's normalcy, success and relative ease with which her sister appeared to move through the world. Sonya stated that she often binged when she went to her sister's house. She always felt that "she was perfect and I was a jerk. I felt ashamed." Therapist's log, session 11. The sibling rivalry had not come up before now. Sonya had been quite careful, in fact, to say how much she loved her sister In spite of her sister's erratic support of Sonya. Why was it finally bubbling to the surface? Session 12 December 10. Sonya arrived saying she did not want to come today. She was feeling abandoned by Jason. She stated that she was feeling a lot of loss and was afraid she would never find "that kind of person who is so real. And I am so sick of being alone. And I really trusted him. This is what I am really hurt about." Sonya also stated that she was feeling abandoned by everyone else as well, which made her feel angry. Sonya explained none of her family members had asked her about her Christmas plans and even strangers had been awful to her of late. 93 We determined to do a guided imagery attempting to access her little girl. She was unable to connect with her little girl but she was able to find some comfort in visualizing herself soaking in a hot bath, which was one of her favorite things to do. Sonya then did the TST again. She described how she felt the world saw her as (Figure S12.1), "feminine, outgoing and strong, pretty, smart, and powerful". She described what she saw when she looked at herself in the mirror (Figure S12.2) as still seeing "a lot of pain and sadness. But my skin is glowing, "three people said that I was glowing and that I looked so different. My skin is better. I am taking care of my insides a lot better than I ever have. I don't get sick as much. I still feel fat but not as fat." As she drew her inner healer (Figure S12.3) she said thoughtfully, "the blue is like the universe. And the yellow is the yellow brick road, I've always said that was life is.. .already mapped out". I commented that the wizard looked like a little girl. Sonya agreed that the wizard had become a girl. She elaborated on the meaning of the blue, "it is a power.. .1 am surrounded by it. I don't know. It's part of me. It's strength, power." Finally she added the dove. As we finished the TST we reflected on Sonya's progress throughout the sessions. Therapist's log, session 12. I suspected that Sonya was feeling abandonment issues around our sessions completing, not only around the breakup with Jason. To that end, she did not even want to come to the final session. Since this was the last session, I felt the only thing to do was to shore up her defenses and try to help her mind find a comfortable place. The bathtub visualization seemed to help. Figure S12.1. "How the world sees me": There was neither any black in this picture not a body. Rather, Sonya drew five solid blocks of colour representing different aspects of herself and four blue birds. The colours represented femininity (pink), outgoingness (yellow), prettiness (purple), intelligence (green), and powerfulness (blue). She felt the birds symbolized her free spirit. 94 Figure S12.2. "What I see when I look in the mirror": Although Sonya had clearly depicted an unhappy, crying person, I was delighted to see that she had used pink suggesting both femininity and the quality of a new-born, feistily coming into the world. This idea was underscored more in that the figure had no clothes on. The lack of a groundline suggested an uncertainty about footing. I was not clear as to the absence of a nose. Figure S12.3. "The Inner Healer": I was amazed by both the care with which Sonya drew this picture and the amount of detail she included in it. The man wizard had turned into a girl (not yet woman) wizard. Her arms were outstretched in an open, and comfortable way. She stood on a proper groundline. The wizard stood smiling at the beginning of the yellow brick road suggesting the start of an important journey of self- discovery. Above the wizard's head, Sonya had written the word, "dove", suggesting the attainment of a kind of peace. The birds suggested freedom and support. The willow tree had become a forest of evergreen trees. Telephone debriefing, week six. Sonya had become very suicidal again. I spent a long time on the phone with her until I was sure that she would not do anything to harm herself. She promised to see her doctor and she had plans to continue in therapy with another woman with whom she had already worked. I suggested to her that she seriously consider anti-depressants. Alison Session 1. November 2. Alison left her coat on for the first session. She said she wanted to feel protected. As she began drawing, she quipped that it reminded her of her childhood. We talked about Alison's pre-school childhood which she remembered as being idyllic, after which time she reported "there is nothing good to say." One of Alison's earliest memories was of great disappointment and injustice wherein she missed out on receiving Easter eggs because the teacher had forgotten to put any aside for her. She also talked 95 about her parents never coming to see her win anything at sports day. She never felt her parents were proud of her. She felt all alone and very lonely. Alison felt she could never secure her parents' attention. When she did try to attract their attention, things always seemed to go wrong. She would end up being punished unfairly. She felt they never provided her with consistent rules so she never knew how to please them and be "perfect". In reflecting on her parents, Alison felt in a conundrum now because they were getting older and weaker and she did not feel "allowed" to get angry at them for the way she had been treated as a child. When Alison did see her parents as she had over the past weekend, "little things will irritate me... so it was a really good weekend. But before they left my mom bought me a box of really nice chocolates." Alison completed the first drawing (Figure A1.1) and began to talk about what she saw in it, "I don't know, when I look at that I feel confusion. I am in an unsettled place right now. My parents have come and left. I have all these really deep loving feelings for them and I still have a lot of resentment and every time they leave I get so screwed up for a couple of days." I asked if resentment and anger she had was not allowed to come out. She agreed that that was the case, "I can't do it in front of them. I still have a lot of fear. And it's not fear of getting hurt now. But it is fear that.. .1 know my mom is trying the hardest she has ever tried to have a relationship and she is real sweet and everything but it's.. .and I know that once I tell her not to do it with the food that it'll hurt her she doesn't know any other way of doing this. She needed to leave something with me. I feel guilty if I don't eat them (the chocolates), she spent money on them." Alison talked about her dad telling her over the past weekend to take a bookkeeping course. She was hurt by this because it had nothing to do with who Alison was and she felt her father had not been sensitive to this, "My dad's a controller. Controlled me through my whole childhood. Controlled my feelings, controlled the way I look, controlled the way I acted. Who I saw. I was very isolated. I was never allowed to have friends because they didn't think Canadian children were good enough." 96 We talked about how much she loved the man with whom she was currently living, Jordy. She was happy with him but she was afraid of herself, afraid that she would do something to jeopardize things. She worried that she overdid things, i.e., making way too much food for a small party...over compensating and taking too much control. She stated, "because I do go out of control.., my food. I can't control my food. I try to control it. It's like I try to take control of everything but for some reason in the end it controls me more than anything." She felt deprivation was a real issue for her. As Alison completed the second and third warm up drawings (Figures A1.2 and A1.3), she talked about her overwhelming concern for the welfare of animals. She worried about how the wild bunnies in parks lived. She talked about making every moment special for her bird, Caesar. She did not worry about special moments for herself. When we started the TST, Alison felt she was unable to draw anything in response to the first drawing (Figure A1.4), "How the world sees me". She explained, "I don't think they see me, like I don't think I really matter. I try to think I do but I don't think anybody sees me so I don't see anybody really seeing me." She left the paper blank. As she drew the second TST drawing (Figure A1.5), "What I see when I look in the mirror?", Alison started talking about some ugly jeans she owned. She felt compelled to wear them anyway, "I've got this thing about you can't waste money. And yet I do. I waste money on, if I am really not feeling good about myself, I will go on a shopping spree.. .clothes, records, it's kinda like trying to get everything I can to put my life back. If I have everything I can start with a just perfect...of course it never works out but...but I know it now. If I see somebody else and say, 'boy they look nice'... I'll try to copy that. I am trying to see exactly what is me. And I wanna be like everybody else." In response to the final TST drawing (Figure A1.6), "My Inner Healer", Alison said thoughtfully, "it would probably be my seagull. I was always fascinated by seagulls.. .I've always sat there and thought, wow. It used to hurt me when people said, 'those scavengers'. I see them as being able to live a life free from any rules. They sit there and they go in the 97 garbage piles and the whole bit and they go through so much hardship." I asked Alison what she meant by hardship. She began to cry, "I get very emotional. I just get really upset about how people can not really see that any type of animal is just, they got feelings. And I don't know how they live or how they feel or anything but they have their own lives and I don't like the way people will walk over anything to get on with their own lives. And that's a real hard issue for me. It has got its own life and it has got its own way and it's happy and it's not affecting us? So it's like how can people... .1 just don't understand how people can be so cruel. And I am not saying that I am a saint or anything. I can be cruel too and the whole bit, I know that, but, it's a real touchy subject for me. I won't watch movies with animals. For some reason, it's something that I hold." I asked Alison about animals in her childhood. She sighed, "Nothing was mine, they were my parents, okay? The first animal I can remember was a dog. And the dogs were always my dad's dogs. He had a shepherd, Suzie, real cute little thing." Alison stopped and began to wept, "And it got hit by a car...and he blamed me...the dog followed me across the road. He beat me up for it. And then, um, like I've really tried to get over this but it's a big issue.. .1 was, what, five years old. It was awful to watch the dog go through that. I think it died right away but I saw the whole thing and I could just see focussing on, what, you know, the state it was in. And they buried it in the ground...and having to watch them do this." She stopped crying and her voice became cold, "And my dad saying, 'it's buried and I don't know if it's dead. 'And I'm sure it was dead." I asked Alison whether she felt that her father loved the dog more than he loved her. She answered, "well, he never wanted me, to begin with. So I know that. And I think it was very hard for him. Like, he loved us.. .but he just didn't have time for us. We were a nuisance in his getting ahead. And then he had another shepherd. And this one was one of those dogs that was just a dumb shepherd but he was so full of fun. And, urn, that was one dog they wanted to get rid of because he was a nuisance when they were building the house...the dog was constantly cutting his feet." 98 Alison finished the final TST drawing (Figure A1.6) and began talking about the seagull's freedom. She agreed to a guided imagery exercise. She discovered the seagull in her stomach and reported, "it's always cocking it head and listening to my responses! It's as if it is always waiting for me to say it's okay. Honestly, I think it is just sitting there listening.. .waiting until I can say what I need to say. It's like there's a secret sentence or an allowance to give myself and I don't know what that allowance is, so I am not really prepared. It's like I have to go through something... "I think I need to let go.. .of the past. I KNOW I need to let go of that. I need to be more understanding. I don't know if understanding but not to take all the cruelty that ever goes on on my own shoulders. I feel everything, there's always such a black side to everything. I will look at the black side before I look at the positive. And I know that I would like to look at the positive but it is like, so hard to remember to keep doing that." Alison talked about she felt things were so black and white; how she felt mostly black, and how she felt so responsible for animals. At the same time, she recognized that this responsibility was unreasonable. She felt she had to make some changes. The seagull suggested she, "accept myself the way I am. Ummm. I can't change myself. I can't look at other people and constantly think how they see me. And, I've got to put my, it's like I see a black part of me and I have been seeing a little bit of the light and that's really neat but on bad days, on bad days they are bad. I don't let the grey come it and I am really hoping to be able to do that." We finished the exercise and Alison talked about how embarrassed she felt doing the exercise. At the same time, she appreciated her experience, "it was ldnda neat to think. I don't know why seagulls always come. I guess it was the first animal that I saw that was free and big. But it's ldnda neat to know that I have a deeper sense of this animal. It's a warm feeling." I asked her to reflect on the seagull until our next session. 99 Therapist's log, session 1. I was quite taken aback by Alison's overwhelming emotions around animals. She was very upset. I wondered how much she related to the animals which she saw as helpless, vulnerable, unprotected, and without a voice to defend themselves. Figure A1.1. "Confusion": The drawing appeared to be an assortment of brightly coloured, labyrinth-like circles interspersed with what looked like a black-faced smile, a cage-like image, and several sets of water-like squiggles. Figure A1.2. "Isolation": The house was set in the middle of the page, away from anything else in the picture. The frame of the house was yellow and barely visible. The chimney, the door, the path, and the birds flying to the left of the house were all depicted n black. The front panel of the house was purple (spiritual?). Green (health, society, friends) finger-like protrusions reached out to the house but did not touch it. Figure A1.3. "Bird": The bird stood firmly on the bottom of the page staring off to the right. Its body took up a large portion of the paper. Its stomach and tail were depicted in soft looking pinks. Figure A1.4. "How the world sees me": Alison left the page blank. She did not believe people saw her at all. Figure A1.5. "What I see when I look in the mirror": This drawing showed a rotund, breastless, boyish-looking person outlined in a light grey. The feet were drawn so lightly, they were almost invisible. Her hands looked more like wings than hands. She had taken special care to almost 'seal off' her neck, waist, and cuffs with the colour purple. Figure A1.6. "My Inner Healer": Alison drew a seagull which she had placed in the middle of the page with no groundline. The bird was looking and leaning to the right almost expectantly, as though it was waiting for something. 100 Session 2, November 5. Alison took her jacket off for the first time today. She began by talking about the discrepancy between Alcoholics Anonymous and Overeaters Anonymous meetings and how she felt uplifted by the former and depressed by the latter. She often found she wanted to eat more after an OA meeting and yet felt fine after an AA meeting. I asked if the two programs were not based on the same thing? Alison agreed that they were but her experience of them was definitely different. She elaborated, "I would say at AA I am a lot more open person. I can talk about it and I don't see the shame in it. I had a problem, I got over it and I am following the steps and life is good for me. OA is, um, there's a lot of shame there over the food and the abuse of what I have done to my body. It's a more physical thing too." I asked Alison to draw the two different Alisons at the two different meetings (Figure A2.1). As she drew, she talked about a dream she had had the night before, "it was weird. It was like words were coming at me. 'Am I right or and I wrong?' It was like this huge debate." The debate was about stopping OA for a while and she felt good about it. Then Alison said that she had eaten too much last night as she had for the last five nights, but she had decided to "keep the food. I haven't thrown it up or taken any laxatives or anything, so I am living with it. It's a first and it's uncomfortable." Usually, at the end of the fifth day, her pattern was to "take laxatives or I'd throw it up or I'd be exercising like mad." I asked Alison why she had decided not to purge this time. She was unclear, "I don't know, maybe I am taking responsibility for what I am doing. I am trying something. And I feel okay. I know for one thing I couldn't continue eating. Today was a clean day. Tomorrow will be a clean day, I know that. I shouldn't say I know that. It feels that way. Today wasn't easy. Even coming here. It was like what shops should I go into to binge. And I did come across another thing. My first binge food is chocolate. Whether or not that's what I am thinking about. I could be thinking about whatever I saw someone eat last." 101 I asked Alison about the meaning of the chocolate her mother had given her last weekend. She exclaimed, "that started me on my binge! That, that, that was it. That's when I started binging." Alison did eat some of her mother's chocolate, but not all of it, she didn't want to eat all of it. Rather, she went to other chocolate sources. She felt it was a way to kind of assert herself with her mom. Alison paused as she completed her drawing of the AA Alison and moved onto to drawing the face of the OA Alison (Figure A2.1). She described why she was drawing her OA face in a certain way, "cause I don't have an expression on my face, I try to, but I know, deep inside, I am blank. I am an isolator. I like to isolate. And my body is very fat. I guess, in a way what I do is I really know all my defects. They go on and on and on." Alison observed that she liked to talk at AA meetings because she "did not feel judged" - this experience was the opposite of her feelings at an OA meeting; she felt "empty at those meetings. There's something I didn't get. First of all because I see myself as a sort of failure when I am going in there because I am not lifted." I wondered aloud whether one of the reasons AA meetings may have felt easier for her was because, unlike her eating disorder, she had overcome her drinking issues. She agreed, "Yeah. And maybe it is easier because those urges aren't there. And I feel a lot more spiritually connected so I know there's that inner stuff. When I go to AA I come out knowing there is a God.. .there is something taking care of me. I can feel it. It's a definite feeling that I get. It's like something hugging me. And when I am walking around there's something there." I attempted to clarify what Alison meant, "from the outside in they are hugging you?" Alison confirmed, "yeah. If I'm really alone...yeah...I'd say from the outside it.. .and not from the inside I never thought of it that way. No, it's outside cause that's how I feel. I know somebody has wrapped their arms around me and it's okay, I've got protection. I don't know what God is." I asked Alison to clarify for me how the experience of drinking was different for her than the experience of eating. She explained, "drinking took it all away. That took 102 everything away. I didn't have to deal with anything. The food really keeps you in it. It makes me more bitter. It's longer. It's just a longer form of punishment." I clarified further, "okay. So eating accentuates the feelings and it feels good in a twisted sort of way because you are getting the punishment you deserve." She nodded, "yeah, and I use food to bring my emotions out.. .my feelings. While I am purging that's when I start to feel sorry for myself. But when I am eating, it's like I am feeling that fire." We then talked about binging and chocolate. She carried explained, "and I know I get very angry. Very bitter. I can't say that I don't like chocolate but I have very negative feelings toward chocolate. I don't enjoy it when I am eating it. But for some reason I want to stay with the chocolate. And I know it brings.. .it doesn't bring back some memories specifically with chocolate. I know when I was going to school, I was in elementary school and my mom never had time to make lunch so she would always give me a dime to buy a kit kat." Alison elaborated on how ashamed she felt in front of the other kids that a chocolate bar was her lunch and that her mom had not made her anything. At the same time she defended her mom explaining that she was busy, "but the chocolate still means a lot and it's something that I know I have to keep away from because it just fuels me too much." We decided to do a guided imagery exercise in an attempt to talk with the chocolate. She discovered it in her stomach. "it's a forbidden, it's always kept away from us.. .the chocolate. It was always kept away. I always had lots of questions and it's too bad I couldn't..." She asked the chocolate why she could not have it and learned that it was a way her parents could have power over her, "cause they had control of everything. You know, no matter what I would want or like, everything was theirs and nothing was mine. Even if they would give me something." Alison said she thought her mother told her to buy chocolate at lunch because her mother felt guilty. "I guess maybe that the chocolate was one of the first times where I realized how much control my parents had. Like before, I didn't know. I was just told what 103 to do, shown what to wear, how to act, what to say and everything. But it was grade one where the chocolate first came and grade one was the first association that my parents kept me from other children. So I can relate with the chocolate being the first thing that they used. It was the first thing that they used to get control of me." I observed that Alison sounded like she really resented the chocolate. She concurred, "yeah. I mean I can't say that I don't like chocolate...but...I have a very difficult time. I can never have a piece of chocolate and go that was very good, it's like there's always stuff around it. Where I could have a piece of cake and feel great and then let it go and everything is fine. But I know the chocolate will just promote the binges and it'll keep it going." I queried, "the more chocolate you eat the more starved you feel?" Alison nodded, "it makes me really depressed. I get really inward there. That's kind of my buddy, sort of. Just going inside myself. That's kind of like my best friend. I mean that's what I had to grow up with cause I really didn't have real close friends." I asked Alison what her 'best friend' thought of chocolate. She replied her internal friend was not interested in chocolate, "because maybe what I don't do is talk to my buddy when I am in the food. And so the buddy is what I talk to when I am okay. It's that gut feeling maybe. Maybe it's my gut feelings that I talk to or basically me. But I know that it wouldn't want. I doesn't want the chocolate.. .cause I get too self-absorbed in me and what has happened." Alison laughed and announced that she definitely did not feel like chocolate after our imagery exercise. The first thing Alison declared when she finished the exercise was that she was worried she would forget what we had explored and learned. We talked briefly about her strong need to be organized, write things down, and be perfect. But, she said, in an exasperated way, "I am so normal. I wish I could have excelled in something. Like some people were real perfectionist and they did fantastic in school. And I was just a normal student no matter how much I studied." 104 We began talking about the colour black. Alison said it was a colour she used to wear all the time. She said now she wears bright colours but she still felt that the black was in her face, "and I know that through school, I always had hair down and bangs and didn't want anybody to see me. Even if I felt good I still didn't want people to see me. Now, If I am backed away, and I don't look at anybody, nobody can see me. I don't think I make a dent in anybody's mind. Unless I make contact with somebody. And look each other in the eye. I don't, I don't exist sort of." She drew a picture of her black self (Figure A2.2). I asked Alison about connecting with her parents. She said it was very tough. Especially now that her dad was actually hugging her sometimes. Alison said this made her feel guilty that she could not express her feelings in front of them. I commented that I felt part of her wanted to forgive her parents and part of her wanted to scream at them. She murmured, "yeah... there's that part of me that just hates them. I hate them. But I mean they are old people. They are getting old and I know they did the best from what the could have done from what their childhood was like. And they had it tough... so I can see all that but there's still that part that says I am the one that is living with the crap, their life is good. They know there is something wrong with our relationship but I am the one that has to get through this. And it's like I have missed quite a few good years." I asked Alison to elaborate on "the crap". She took a deep breath, "I can maybe get two good weeks of having a real normal life like normal people and then there will be that food stuff. Just hating myself and having absolutely no control. I mean, I manage to get up and go to work. I do that necessary stuff. I'll go to work. I'll pay the bills but everything else is screwed up. And, I mean I am the one who does it, I know that.., to myself." I asked Alison to draw her feelings for her parents. She drew a stop sign (Figure A2.3). As she drew she focussed on her feelings, "I think the hate is getting smaller but it is still there. And then I have a lot of compassion cause they are getting older and their health isn't' good and my mom has to take care of my dad.. .1 feel a lot of compassion, I would do anything for them. If I had money and that I would just give it. So I have 105 compassion, hate, anger and guilt, I have love.. .it's not a warm love.. .like my cat I love my cat and I want to cuddle. The love I have for them is love at a distance...like it really wouldn't bother me if I never saw them ever again but I need to know that are taken care of, they have a great life and that won't affect them." I commented that I felt as though I was listening to someone talk themselves into going to the dentist." Alison protested, "I think I love them. I mean I really do I CARE about them." She stopped and began to cry, "and it hurts to see them. Cause they are getting older and I am angry because we will never be that, I will never have that family I always wanted and it doesn't matter what happens now, we are never going to have it. So it's kinda like I go 'big deal' and I just don't wanna be a bitch. I don't wanna hurt them but I really wouldn't mind if I never saw them again and that hurts! And I don't think they would ever really like who I was. They would always be disappointed no matter what. And I still try. I still try. But I can't do it." I asked Alison about how she felt she was different around her parents. She went through a mental checklist, "I watch everything I say. I am really guarded. I dress differently. I make sure that everything I am wearing would be suitable. I try to make everything sound rosy." Alison then began talking about binging when she is tired after putting on a show like that for her parents, "I know binging just makes me not do anything. Like it is hard for me to turn around and say, I am really tired, mentally, or physically so just take the day off. I can't permit myself to do that so when I binge. I can't have a normal day, I have to basically sort of relax and do nothing and eat. And I know that is one of the big things. But it still, it still controls me more that I could control it. That's frustrating." As we finished the session, Alison said she learned a lot but she felt angry at me for getting her to talk truthfully about her parents. I thanked her for her honesty. Therapist's log, session 2. I appreciated Alison's ability to differentiate between her OA and her AA experiences, particularly since the formats are supposed to be so similar. 106 For Alison, they were very different events. Her dearth of spirituality in the OA was surprising. Alison popped her own bubble regarding the nature of her relationship with her parents and yet, clearly, a part of her did not want to explore this area. I was delighted that she had the courage to tell me that I had made her angry. I did not have the impression that being assertive came easily to her. Figure A2.1. "The AA and the OA Alison": Alison had portrayed her OA self as happy and slime with feminine hair and no breasts. She was not standing on an groundline. The OA Alison was more mannish looking and had an expression of trepidation on her face. Figure A2.2. "Black Self": Alison's black self was floating in the center of the page. She was only black from the shoulders up, however. She facial expression was a definite frown. Figure A2.3. "Feelings for Parents": Alison drew a grey stop sign. She broke the sign down into different feelings with extra heavy lines next to the words, hate, which was on the left, (mother?), and pity, which was on the right (father?) Telephone debriefing, week one. Alison felt a lot of material had emerged for her that she had not contemplated before. Her thoughts were especially peaked around my speculation about the connection between the use of binging to help literally bring up feelings. With that new awareness, she felt she could now have a choice, "before I start a binge I hope I will think of WHAT feeling it is I want to bring out". Alison also said she "hurt about my discovery about my parents.. .1 feel like that pushed me back but further ahead too. I didn't know I felt this way. Now I am not going to have expectations that we are supposed to be a perfect family. I will just accept it as what it is." 107 She also talked about having another vivid word dream after our second session. It was about, "a sentence from the 12-step program: principles before personalities". She said that it helped when she went on a shopping spree on the weekend. She stated that usually she bought out of control, but, for some reason, the dream helped her to be stronger, to listen to her own opinion rather than to the opinions of others. Finally, Alison observed that she was really starting to listen to that place in her "gut" where the seagull lived, "something is telling me and I am listening. I feel like if I were to go on a binge right now, it would be fake. Going on a binge would be hypocritical." Session 3, November 9. When Alison arrived, she was in a bad mood. She said she was really feeling like binging, "I know these feelings so well"... "why am I at this edge to begin with?" She was also feeling apathetic about even trying to avoid a binge.^We began talking about her work environment. She felt that she worked with an "extremely dysfunctional man who was exactly like my father". Alison expressed great concern that she might have to leave her job and actually go "into the adult world" to look for a job. She worried that being at work with that man made her want to binge. I asked Alison to draw a picture of how this man affected her at work (Figure A3.1). As Alison drew she said about him, "nothing you can do is right. You could do something perfect and it wouldn't be right. And I know it's his stuff but...". She moved on to comparing this man at work with her father, "they are always right, they are never wrong. And when a crisis comes up they fix it for them not for the whole crowd. And I am afraid to approach him. It's like he has this shield, and I can sort of like touch it but I can't go too far." Alison described the shield as a "YELLING". She chose to represent the yelling with the colour purple because she felt it was "a frenzy". Alison began talking about the circle she often imagined around herself to protect herself from her parents. Alison also saw the circle as a way to protect her parents from her. She talked about how she tried to show them that everything was wonderful. She 108 explained that she used to think about her father as a kind of "Yelling" as well, until she was able to move out of the house when she was 19. Alison also talked about her mother and the great disappointment she felt in not being able to talk with her mother like a real friend about real things. We talked some more about the man at work and I suggested we attempt a guided imagery exercise to further understand her relationship with him. Alison expressed a great deal of concern around the fear of discovering something that might make her want to leave her job - a prospect she was not prepared to consider. However, she also did want to go ahead with the exercise, we proceeded under the condition that she was to speak up if she felt uncomfortable in the least. As we went inside, Alison's thoughts took her to the top of her stomach. I asked about her sense of the feelings that were swirling around in her stomach. She replied that she was feeling "frustrated because of yesterday" when Alison had developed a real craving for chocolate. She felt that the chocolate had to do with the fear she was feeling around the promise she had made to visit her parents next weekend, "I am really feeling pressured, I don't want to go. At least I don't want to go over night." Alison felt unable to tell her parents that she only wanted to visit for the day. Alison was afraid that her parents would simply not accept that. Part of her concerns revolved around the feelings of wasted time in that "they don't talk about anything real". We took a moment to explore Alison's feelings of frustration. She perceived that part of the frustration was an obligation she felt around her parents because, "I owe them so much". We finished the exercise and Alison reported that she was, "feeling safe.. .it's like now I know I won't go home and binge." Alison also took pains to explain to me that she was "still keeping her food" In spite of her anxiety about her visit with her parents. She felt she was still exercising a bit too obsessively however, she was not throwing up or taking laxatives. Alison also expressed surprise that she actually "admitted" to me that she had eaten some chocolate. I tried to underscore that I had no expectations of her behavior. 109 Alison stated that she appreciated practicing a conversation with her mother around how she wanted the visit to happen on her terms: Therapist's log, session 3. I felt as though Alison had done a lot of work this first week. I was also aware that she had started to move into unfamiliar territory and I felt extra cautious about moving slowly and really ensuring that she felt safe. I was quite surprised to hear about the striking similarities between the man whom Alison abhorred at work and her father. I was also struck by the fact that she had worked in the same job, with the same man, since she left her father's home, 13 years ago. She expressed what felt like an inordinate amount of fear around leaving her job. I wondered about any connections between unfinished business between Alison and her father. Why did Alison feel that she would have to leave her job if she rethought her feelings about this certain fellow employee? Figure A3.1. "The Yelling Man": Alison had depicted herself with no hands, feet, clothes, or groundline. Her body had no substance. Her arms and legs were extended in a vulnerable way. She coloured the black cloud over several times. The purple shield felt as though it may be somehow blocking Alison's access to her own spirituality. Figure A3.2. "The Protector Aura": There was a softness about this drawing. The brown figure looked like a stick from the earth, undefined, androgynous. The green may have symbolized a kind of healing effort. Session 4, November 12. We began by discussing the phone call Alison had had with her mother, which we had rehearsed, regarding Alison visiting her parents on the weekend. Alison had held her ground with her mother but felt very guilty for doing so. She had had a strong desire to binge since the call. She had gone on a "controlled binge" but had managed to avoid the trigger food, chocolate. Alison stated that she was thinking of stopping exercising altogether for a while. I commented that this was a very black and white way of doing things. She sighed and said she wished she could "just let go". She felt 110 other people could be very casual about the way they exercised. She was afraid to let go. Alison also felt that she had had a voice in her all week trying to make her do "bad things". She reported waking up early that morning and hearing a voice in her head say, 'don't exercise'. Alison felt it was not a kind voice. It was malicious, savouring the fact that she was being "lazy". As Alison spoke, she used her right hand (male) to discuss the presence and then held up her left hand (female) to refer to a kinder presence that just let her be sometimes. I asked Alison to draw the two sides (Figure A4.1). She drew some narrow rectangles on the right hand side of the page which she explained talked to her in a deep male voice that was very authoritative and demanding like her father, "you wouldn't say no to this voice". On the left side, she drew undulating, pastel-coloured waves that were gentle, easy-going, listened to her inner self and would say not to exercise because she was simply tired. Alison felt that the waves were genderless and felt like a breeze going over her body. She felt the male voice was like the devil...she felt as though these two parts of her were "split like two people". I asked Alison about how the two sides worked when she talked with her mom. She reported that she often felt like a little girl. I asked her to draw this (Figure A4.2). Alison drew a 12 year old girl, "because that is when I started to want to have my own opinions and I couldn't." I asked how we might be able to raise the 12 year old into a woman so that the woman could talk with her mother - would the seagull talk with us? Alison felt, for the first time ever, that he would. As we prepared for the guided imagery Alison announced that the seagull was flapping his feet because he was so excited and happy that we were going to talk with him. We moved inside and asked the seagull what Alison could do to encourage positive communication in talking with her mom. 111 The seagull had five specific recommendations: 1. The change won't happen over night, be patient. 2. Surrender to spontaneity in life.. .don't plan everything so much. 3. Trust your internal wisdom.. .you know more than you think you know. 4. You will learn for a while and you then hit a kind of critical mass where it will all come together. 5. To take care of yourself, meditate. Following the conversation with the seagull, Alison reported that the seagull was very happy and felt like he had "released a bunch of helium balloons". Therapist's log, session 4. I was fascinated that Alison, like the other two case studies, appeared to have a sense of an internal dichotomy. She felt she was split into two people: one of them actually working actively against her best interests. I wondered how this might effect her eating behavior or her sense of spirituality. I was equally struck by the clarity and detail of the suggestions from the seagull. The suggestions seemed to come from beyond Alison's conscious scope. Figure A4.1. "Male and Female": Alison drew the female energy on the left side of the page depicting it as gentle, fine, light waves of turquoise, mauve, and spring green diagonally running the length of the paper. She drew the male energy on the upper right hand corner of the paper depicting it as dark black squares and heavily-pressed blue rectangles clustered together. Figure A4.2. "Twelve year old": Alison drew herself as a 12 year old who was just beginning to develop her own opinions with arms out-spread, a slight smile, a bulbous body, a long skirt, and big green feet. There was no groundline and the figure appeared to float in the center of the page. 112 Telephone debriefing, week two.  Alison felt she had had a good week this week. She found the sessions had helped her do a lot of self-discovery. To that end, she had decided to start meditating. She had also determined not to exercise for a while until she found a motivation to exercise which came from an inside desire rather than an external 'should' for the purposes of dieting. Alison also stated that she was starting to find some boundaries for herself, everything did not feel so black and white. Session 5. November 16. We began by talking about how much Alison had changed over the past three weeks. Alison volunteered that she had been meditating daily for the past four days and it had been very useful. She also stated she felt like binging today but had not. She had had to put her bird of 14 years, Caesar, down. Her grandfather died three weeks ago and "there was no grieving and this was like, real grieving. Alison said that she was learning more about herself and accepting more about herself so she did not feel she needed the "stability" of the bird as much. The desire to binge today had centered around chocolate, "I didn't want to deal with Caesar. I didn't want to deal with the feelings. I don't like people to see how hurt I can be." The chocolate was supposed to keep her busy. Her mom used to give her chocolate to keep her busy. She didn't binge on chocolate however, "I know where it leads me. And it doesn't do anything." I asked about her ability to express her emotions about Napoleon, she cried right away. I recognized that she was in touch with her emotions and she felt safe enough with her boyfriend to express herself. We moved on to talking about Alison's day visit with her parents, "it was real awkward and I could see her trying." However, Alison felt she had managed to hold her own. We talked about what Alison felt she had to forgo in moving toward a new kind of relationship with her mom. I asked Alison if there was anything to which she felt she needed to say goodbye. She cited two feelings: terror, and vertigo. I asked her to draw those two feelings (Figure A5.1). She chose to represent the feeling of terror with an image of a haunted castle with bats, "kinda like that feelings if I was going to watch a horror 113 movie and not quite certain I wanna see all of it". She depicted vertigo with several spiral circles, "a lotta confusion. So at least I know that next time I see them, it won't bother me if I turn around and say I don't wanna do that or that wasn't my plan.. .and yet I know that I am not hurting them because it wasn't a big life plan". As soon as she completed the drawing she happily scrunched it up and threw the paper across the room. I asked Alison about the meditation, "really good, really, really good. I am amazed at the answers I am getting. And I didn't have to ask if it was the right thing to do. I knew it was the right thing to do. And it makes me relax. I used it to decide not to eat chocolate." Alison also stated that her eating, in general has been very good. I asked if the seagull ever entered into the meditation. Alison smiled, "he is always there and the meditation is water.. .1 am safe, I am really safe when I meditate". Alison also volunteered that she had stuck with a conscious decision not to exercise. "but I have to really work at it because I feel so guilty when I don't exercise. The only time I ever had guilt-free days was when I was fasting." We began talking about spirituality and binging. She stated that the two never existed together in the same moment. When Alison binged she just felt, "a big hole." I asked her what she felt at the moment and she chose to draw a vine representing her sense of spirituality (Figure A5.2). In reference to the drawing she exclaimed, "it feels like it is going to come through and keep going. There is no limit. It is like an eternity sort of." I asked where 'it' was coming from. She pointed to her lower belly. She explained that that was the place from whence both the vines and the roots were growing. Alison paused to reflect on how relaxed and peaceful she felt, "like a loose doll. But I feel calm and safe, and I don't feel vulnerable! I know what I want. Sometimes that one little voice comes through like it's only for today. There's that little guy that is just waiting for it to end. That part of me that doesn't want to believe." Alison studied the vine in the drawing and said she knew that "there would always be new leaves coming along because I know I am going to be changing all the time.. .and that's a tough one because I like things to 114 stay the same. .1 used to always want to deal with everything at once and say, now that I have dealt with it I will have a perfect life." The moment Alison mentioned the word 'perfect', she paused and reported that she was thinking about chocolate, "that little voice". I asked Alison to draw the little voice (Figure A5.3).^She drew a black stick figure in a white fish bowl. As she drew the figure she said she was concerned that the pesky little voice may be able to look up and find a way out. She determined to draw on a vacuum sealed top with a lid handle so that only she had the choice as to what to do. Alison announced, "I won't binge today. Before I never had choices. Or they would be shoulds. There's a big difference between shoulds and a choice. And now that I know I have a choice, it's not as threatening as it used to be. He's a lot smaller that I thought he was. If the lid ever came off, he might crawl away, I could just put him back. It's not like he is going to expand or anything." Out of the blue, Alison began talking about not being comfortable sexually, especially with her father. Our session time was up so I suggested we discuss that subject next time. Therapist's log, session 5. I was amazed at how quickly Alison appeared to be moving. Each session she was discovering and incorporating more tools into her daily life such that she could move away from bulimia. Alison seemed to be working especially successfully at feeling her emotions without having to binge as a result. Her determinations to avoid exercise until it came from a healthier place; avoid chocolate; and to be tough, yet kind, in dealings with her mother, all required a tremendous amount of focus. She had progressed very quickly. I would have been more concerned at the speed with which she moved if I had not felt that Alison was the person dictating the speed at which we moved, and the depth at which we worked. Figure A5.1. "Terror and Vertigo": Alison's image of terror was depicted as a splotchy grey and black castle with a little window on the lower left side. A huge tree-like 115 grey loomed on the right side. The castle was on the left-hand side of the page. The image of vertigo was drawn in shades of okra, greens, and blues on the upper right side of the page. The image felt tight and uncomfortable. Figure A5.2. "My Spirituality": Alison drew her spirituality as an okra, brown and green vine that moved vertically through the center of the page with no apparent beginning or end. The leaves on the vines were up-turned, and carefully coloured a vibrant green. Figure A5.3. "The Nagging Doubt": Alison's fear of her desire to binge manifested as a black stick man in white goldfish bowl with brown lid with handle. The man looked little and weak; pitiful in his reaching up to the lid but nowhere near it. It looked like he was falling back and asking for mercy but Alison would have nothing of it. She did not trust this little man who could grow if released...her seal was 'vacuum-packed'. Session 6, November 19.  We began by talldng about how well Alison's meditation was going, how calm she was feeling, and that she was happy with how she had been eating. But Alison expressed that she missed the binges and missed the isolation the binges afforded her. She missed being able to eat whatever she wanted all at once, "in a way I am grieving it.. .it's okay but it's still sad. Tuesday nights were a great binge night cause my boyfriend wasn't around. Now I have to think of what to do on a Tuesday night. I can't sit there in my isolation, now I use it as constructive time. I also miss the time." I asked Alison to draw a picture of what she is grieving regarding the loss (Figure A6.1). Alison observed that when she binged, she was isolated but if she was just home alone, she was not isolated, she is with the house, in the house. Isolation only really occurred when she binged, "I cry a lot, I think about my lack of education (should ofs and could ofs), I think of my finances, I think of the animals that have died (dogs, cats, birds), the people (my family, friends, other onlookers (judgments), the yellow house ("when I think of this I think of how I would like things to be.. .in a house with a nice atmosphere"). Alison described the picture as things she did not have now, she did not "grieve" the above 116 thoughts when she was not binging. I asked Alison about the container in which she had placed all her items in the picture. She said it was a living room, "when I can see myself all I can see is me". Alison tried to remember what these different items meant to her when she was binging. She was puzzled, "it's really hard for me to remember that low feeling.. .what it was like? Something has gone. It's a real desolation.. .like going in a real, hot, dusty desert and you see the road and there is no end and you can't go anywhere else. Now I know that the road goes somewhere and there are exits." Then it dawned on Alison, "I am missing that self-pity. It gave me the reason to not turn around and do something. It was nurturing.. .that's a good word. Like somebody hugging me." Alison looked at the picture she had drawn again and offered her thoughts on the money symbol, "it makes me feel really bleak...I don't like it and I will get rid of it as fast as I can because I don't want to deal with it. I don't wanna be like my parents". Alison's parents worried about money all the time. She appraised the drawing further, "I see a positive attitude toward going through it (the bulimia). The tears aren't there. The self- pity isn't there. Instead of self-pity it's saying what can I do about it? The finances...I am not great, but I am more cautious, not being reckless. It just doesn't seem like such a big deal anymore". Alison laughed, "it feels like the binging was such a long time ago (8 days earlier).. .and it was a forced binge.. .1 had to have a date I could remember...I wanted to make a statement." We moved to talking about the issue she had raised at the end of the last session regarding her discomfort relating to her sexuality and her father. In fact, she felt not just embarrassed, but very uncomfortable, around issues of sexuality and both of her parents. Suddenly Alison began talking about how her father had not wanted children. He did not want either Alison or her brother. She began talking about how he had used a strap, beaten, and kicked both Alison and her brother a lot. She stated dispassionately, "if he was angry it came out in jolts". Alison then began to cry and said she did not want to talk about 117 this anymore. I waited quietly. She carried on, "he was angry, he was always angry, he didn't want us and we just got in the way...now he has all the patience and all the time. My parents shouldn't have had kids... mom wanted kids because she had a lousy marriage with him...used us as a buffer. Everybody was scared of everybody. It was like when I was little, she used us as bait. As she wouldn't use us both at the same time, it would be one or the other. When I was little I got a lot of nurturing but from the time I was six till I left it was awful. First she wanted to control me and then when I was in high school, she saw me as a threat. It was a competition. She always wanted to compete. She would beat me in different ways. She would forget where her scissors were and accuse me. But I don't hate them for it. I am lucky. I never went to the hospital. I don't have any broken bones. I am really thankful." I asked Alison what she needed from the conversation. She reflected, "I would really like to not have fear.. .1 have never talked about this. It's like I have this little debate.. .it wasn't that bad." She told a story of neighbourhood kids telling her that her dad was calling. Sometimes it was just as a joke but she would always run home and couldn't wait till she was hit and the waiting was over. Alison wept, "part of me feels guilty. Part of me feels responsible." Alison wondered aloud, "how did I bring this on? I think about this when I binge too." Alison talked about how, as a teenager, she had tried to portray that she had had a great relationship with her dad. Therapist's log, session 6. I felt as though Alison was at a very delicate point in her transformation in that she had given up the binge/purge cycle for the moment but was feeling a great deal of fear and trepidation about how to replace that experience. If she did not find something that felt adequate, would she return to the comfort and solace of binging? I was struck by how torn Alison was with regard to feelings for her parents, even as she talked about how violent her father had been, she sought to protect him and appeared very concerned that I might think badly of him. Also, when Alison stated that her parents 118 should not have had children, I found myself thinking of the first TST drawing I had asked Alison to do about how she felt the world saw her: she had left it blank. Figure A6.1. "What I lose by giving up binging": Alison drew a black box and filled the left hand side with blue tears. She outlined some of the dollar signs in blue as well. She said the animals represented sorrows of animal tragedies gone by; the people represented judgment; the house represented things that never were; the books represented the education she never received. The drawing was a black box of regrets. Telephone debriefing, week three. Alison talked about having trouble knowing how to handle the extra time she had on her hands now that she was not binging. She was thinking about binging but she was not doing it. She also found she had had some crying spells. She was feeling very sad but did not really know why. She stated she was feeling a lot of fear around no longer being bulimic. Session 7. November 23. We began by discussing the transformation that Alison felt she was experiencing going from being bulimic to being normal. Alison declared, "I know it's uncomfortable but it's not half as bad as the other". Alison reported she was still meditating and had begun to incorporate exercise back into her regime. We talked about the empty space in her life that used to be filled up by binging..."I used to binge, I know the times when I do it, and there's a strange feeling around those times during the day when I might have normally binged. I think I am just going to have to get used to it. I tend to just go through it rather than trying to do anything." Alison told the story of a recent triumph. She was eating a bagel with a banana at lunch when a male co-worker asked her if she wanted to 'gain weight'. Alison declared, "it would have been the perfect excuse to binge; no matter what I do it's wrong. At first I was hurt but what it made me do was to turn around and say to myself, 'hey, I am not eating meat and butter' etc. So I thought, 'no I am doing well right now." I commented on her positive boundary and asked her to draw that boundary (Figure A7.1). She began drawing 119 right away stating that, "it's got real solid walls but I had to really work at it. The yellow is me processing it. I made a list, his points and my points, and our points over lapped. I had to look at my whole day. It was a good feeling that I could do that." We then explored the mysterious waves of sadness Alison experienced over the weekend. We determined that it may have been related to unfinished feelings filtering out. I asked Alison about what remaining chunks of sadness needed to be dealt with around communication with her parents. Alison mused that there was "a dimension" to get through because she had things to say to her parents as they were, not as they are now. We embarked upon a guided imagery conversation between Alison and her father. She told him that she was afraid of him when she was a child and that she felt he did not support her or teach her responsibility. Alison talked about she felt different from the other kids, "It hurts to be different and if you want me to be different, let me be different in my own way. I know you wanted the best for me, you would have paid for all my education, but it would have been your education. I had no clue what the world was like, I was so complying and so scared. You didn't have to hit so hard. I didn't like the way you hit me. You disciplined us in so much fear. Not to learn right from wrong but to make us fear everything. We were humiliated. Everything we did we were humiliated. When I was 8 years old you had me washing floors till 12 o'clock at night." Alison stated that she wanted her father to acknowledge what he had done so that she could move on with her life. She asked him for an apology which he finally gave her. Alison turned her attention to her mother whom she deemed to be bitter, jealous, and also very cruel. Alison felt her mother "wanted to hurt, and to humiliate, she was angry that I was a girl.. .1 was something to keep pulling down and kicking... she felt that way about herself. I felt sick, I felt like crap". 120 Therapist's log, session 7. It felt as though Alison was in the midst of courageously moving from one world to another. She was bravely and consciously experiencing the transformation from living her life outside her body to moving into it and claiming all that was hers. She appeared to be learning what it felt like to live inside of herself accepting all the privileges that go along with being an autonomous creature in the world. Figure A7.1. "Thick Wall": The wall is big and drawn with bright and happy colours. Alison said she felt safely protected and yet, because of the light colour, able to communicate with others quite comfortably. Session 8, November 26. Alison had not even sat down before she began talking about the anger she felt toward her parents which had emerged the day after last our guided imagery exercise. Alison said her anger had lead to a "controlled binge.. .it's what I used to do when I got this angry. I forced myself to have chocolate and then I said, 'no I just don't want it'. Which is really neat. What it was, was that I thought that the conversation I had with my mom and dad was crap. Number one, I am angry at them. I am really, really angry. To be honest, I want them to have a wonderful life. That is true. But I don't want to be included. I really would like to get on with the rest of my life with not having to deal with them. For me it's not hurting them, it's me getting on with my life. I just don't want to deal with them. I don't want to be bothered. I was determined to say, you can't do this to me anymore. I was real angry. I didn't need to get rid of the food. I didn't take any pills, I didn't throw up. I didn't exercise." Alison paused, took a deep breath, and smiled. I asked Alison where she had felt the anger in her body. Alison pointed to her upper chest, "It's like banging on a door. Let me out. Let me out of here. And all you have to do is open the door...let me out of here." I observed that when Alison was nice to her parents, she felt awful inside because she found herself vicariously condoning their behavior toward her when she had been a child. Alison agreed and yet she felt she could still never do enough for them. She always felt, "I've got to do more, better." Alison paused and then began talking about how she 121 handled anger when she was a child, "it was like when I was little I used to have tantrums. I never had 'em in front of anybody. And I would start pouring everything into the middle of the floor in my room, I made sure nothing got damaged. That's the type of anger it was. That anger that I can't vent." Alison reflected on her parents now that she was an adult, "when I see them, it's ldnda like I am looking at someone who doesn't have any face. And it hurts. It's more sad. Two old people and I am not going to change my feelings toward them no matter what. When the day comes that they are to go.. .1 feel, it's like a relief. I was trying to prove I was that perfect person who wanted everything to be nice and that's crap. It's wouldn't bother me to never hear from them.. .and that feels so good! It just feels so good to be able to say that! A lot of the times I will feel so guilty that I will phone them. I am hoping I don't have to put myself through that anymore." We determined to do a guided imagery in order to visit with the seagull. Alison discovered that the seagull was frustrated. She reported that the seagull knew she was scared about hurting her parents' feelings but that she needed to get on with her life. The seagull suggested that to move forward Alison needed to "forget who I was. He get's angry when ever I turn around and say I don't want to hurt them. He gets really pissed off because it's like, you are not going to hurt them. I think there's a bit of ego there. As long as I keep doing that I am not going to get on with my life. I have got to quit compensating, he says." When we finished the exercise Alison commented that she would like to remember the bird the next time she is in a difficult mood. "I feel a little more comforted knowing that he is there than I do knowing that there is a God there. I have to work harder with God. And with the bird, he is working with me. It's like he is there and I know that and no matter what, if I go wrong, he'll be there. He's in my solar plexus and it seems like he is getting bigger or he is fluffing out or something. It's like it protects me outside but the bird protects me inside. And I think God is protecting me from the things outside of me...I will always be taken care of at work and things like this. The bird is going to protect my 122 feelings. So if I am going to get really angry.. .maybe I can talk to the bird. I wonder if I could meditate on that. It may be kind of neat 'cause then I could have a one to one contact with it...emotionwise...learn what to do with my emotions. Anger, anger is hard for me to show, it's like I always have this great big huge smile on my face, to soften. And I get so angry at that because it is so pathetic." Alison expressed surprise at how much emotion was starting to come out of her. She talked about wanting to get involved with more people and wanting to buy some books to learn more and grow. She said she wanted to read more about meditation because, "it's making me an individual. It's giving me my own thoughts. When I mediate in the morning, my parents, my boyfriend, no one's there but me, my thoughts. It's giving me self- confidence. I can do what I want to do. It feels really good." Therapist's log, session 8. I was delighted to experience Alison exuding so much uncensored emotion. I felt as though I was watching a fever finally breaking. Alison had stopped being "nice". She was very real, and passionate in her expression of her feelings about her parents. She felt alive! I was memorized by Alison's distinction between the internal, healing seagull and an external, protective God. What does this mean? Telephone debriefing, week four. Alison announced that she was starting to make very strong boundaries. She felt the meditation was continuing to help her to open up and to relax. Alison determined that she did not want to go to OA anymore. She did plan to continue attending AA meetings because she was empowered by them. Alison felt that she was learning to concentrate on her inner self now instead of concentrating on food. She felt that "food is a symptom, it is not the cause". Session 9, November 30. Alison began by saying she was feeling some self-pity today because her boyfriend was taking a course and paying her less attention. She observed that she felt the emotion but she did not binge. Alison felt that feeling an 123 emotion first, and then feeling like binging, but not acting on it, was an enormous inroad. Alison said she had really been tempted to feel like a victim. She wanted to feel self-pity, which she observed could have moved into anger which could have then provided her with the energy to binge. She paused, "That's what I used to do. One thing would trigger me and then I would bring out a chest full of experiences. It would just make me feel worse." But Alison had not done that this time. She observed, "I learned to sit back in these feelings. Not to try to take control of them. To feel them and not to turn them around. I could have made that pity into an anger." We began talking about a possible connection between Alison's sense of sexuality and food. I asked Alison how she felt when she was looked at by men. She frowned, "it would make me feel like I loathed myself. Like I need to hide me. Everything about me. Anything sexual about me." Alison began talking about how her parents had treated the topic of sex. When she was a teenager, her dad used to always infer she was having sex. Even when she was 28, her mom gave her a rough time about being 'a slut'. She always had to think about what she was going to wear when she saw her parents. We talked about developing more protection for herself for when she visited her parents. Alison drew a picture of a screen (Figure A9.1) that would allow her to show love but deflect mean blows. To further ensure her emotional safety, she drew an envelope into which she could put mean or upsetting comments and send them back or away from her. We talked about her meditation in which she recently spoke with the seagull. She smiled, "we were like two really good friends just sitting and watching the stars at night. So he knew I was there. I felt warm, safe. When I start to think of the seagull more that's when I start to take care of my insides and that's when the outside is taken care of better. This comes way before the outside. It's like my insides are heating up before the outside." Alison explained that she was just looking at each day... "and I am not looking too far behind me. It is too close. I am afraid I could get sucked back into it." 124 Alison commented she had backed off the exercise again, and had to "work at not looking at my outer self. I am having a little more trust. I know that what I am doing is fine. And, as the food goes, I will never be 200 pounds. There is a little bit of concern that I could control. But it's like I don't really want to do that anymore." Therapist's log, session 9. I found myself constantly struck by how fast Alison seemed to be progressing: being in her feelings, coping with daily hassles, and clearly seeing what her normal pattern would have been in the past, what her new pattern was, and responding to the challenge to continue to make the transition from one to the other. Figure A9.1. "The Screen": The brown (excrement?) figure was on the right-hand side of the page with a light blue screen (like water.. .the subconscious?). The envelope on the upper left part of page was flesh coloured with a big black seal. The foreboding quality of the seal almost suggested that the contents were poisonous. Session 10. December 3. Alison arrived in a good mood and immediately began expressing the difficulty of "dealing with life on it's terms and not having a crutch to deal with it". Alison was finding when one little thing went wrong, it was easy to use that as an excuse to start being hard on herself. In general, her new way of being was a daily struggle, "it's hard going through the motions. The food I am eating, I am keeping. I am eating healthy. There's no junk and no chocolate but I am used to living on a muffin and a banana and a binge and getting rid of it. I am not used to eating normally. I need to get rid of that outside self-consciousness. I am going by common sense knowing right now my body is going through some changes. I am being easy on myself but I am going through all of this turmoil. I am not going to binge. I am not going to start playing those mind games again. But, it's really have that belief that it will turn out well. It's like, oh my God, how do people eat normal!?" We talked about the challenge of learning what to replace the unwanted eating behavior with. "I don't want to go back to that superhuman again. Because I will burn out. But it's just having the patience day by day." We talked about the fact that 125 Alison had made a decision, had some broad strokes in her mind of how to build her new way of being, but she did not feel she had the details down pat yet. Alison reported she was not feeling deprivation. But she was having difficulty with the TRUST; that it would be okay; that her slight weight increase would not get worse and worse but, instead was just an acclimatization to a new way of being. She was having trouble learning how much she should eat for her size...has no sense of what is actually appropriate for her in a normal, healthy way. Alison was feeling really self-conscious of herself right now... "if this is going to be it, will it be okay for me? Will I get to the point that I really like myself as I am and be able to get on with my day. I get up and my first thought is, 'I can't wait until breakfast." I asked Alison about her meditation practice. She was continuing with that practice, "it is giving me the willingness to know about my defects and resentment so that I can begin to change them." Alison began talking about another man with whom she worked who irritated her because he seemed to be allowed to get away with not doing "grungy" work that other female staff had to do. Alison fumed, "He does bring out rage in me. And when I get angry I think about my parents. So he brings out the anger I have for my parents. It's that unfairness." We decided to do a guided imagery with the seagull. Alison found him in her solar plexus where he was resting with his back to her. She asked the seagull about how to cope with the man at her work. The seagull responded to simply accept him as he was. The seagull suggested that Alison get on with her own life and do her own job and appreciate the people she did like at the her office rather than focus her attention on the lazy man. Alison observed that she knew the seagull was there during the day but that she did not really think about him. She expressed a desire to have him be in her thoughts more often. She asked the seagull to do this and he agreed. Alison finished the exercise. We took a moment to reflect on the potentially deeper nature of her irritation with the her male co-worker. I suggested she may have been attracted to some aspect of what he 126 represented to her and could she perhaps draw that (Figure A10.1). She drew a picture of the co-worker holding his own in any situation; something which she felt she could not do. As Alison drew, she added the word "pop" representing that "if he has to do something, he does it and it is gone..he gets rid of it right away". We explored how Alison could take that characteristic and add it to her repertoire. She felt that she could start by not jumping up to get coffee the moment her boss asked even though she might be disrupting her work to do so. We rehearsed a situation and she felt pleased with her solution. Therapist's log, session 10. Alison appeared to be slowly acclimatizing to a more forgiving and kind way of being in the world. She seemed to have recognized that she did not want, or need, to be superhuman in order to justify her existence. I was struck by how increasingly wise, and supportive the seagull was. I was also amazed by how effortlessly Alison seemed to be able to access that information. Alison appeared to respond really well to the rehearsal we worked on regarding her desire to be slightly more assertive as work. She was excited by the tools she discovered she had within herself. Figure A10.1. "Desirable Characteristic": Alison drew an orange balloon (creative ways to release feelings of anger?) with a big black line in the middle, and a green and pink "pop". The "pop" appeared to be a healthy and a amusing way to diffuse anger. Telephone debriefing, week five.  Alison reported that she was really working with the imagery exercises we did during our sessions especially during her meditations. She felt that she was starting to feel a "sense of power.. .that I do have choices... food is not an issue now." She worried that she might lose humility and perspective now that she was doing so well. 127 Session 11. December 7. Alison began by talking about a wedding she had attended last night. Usually she would have binged the day after a wedding. She did not binge this time but had felt empty.. .she had to fight the feeling which she identified as a "habit". Alison felt that she had done something positive by not binging and she felt very "proud" of herself. We talked about the rehearsal we had undertaken last session regarding Alison asserting herself more at work. She reported that things had worked out well and that she had felt pleased with herself about that too. We talked about her boundaries. She said that each morning when she meditated, she visualized a clear shield which helped to protect her. I asked whether Alison was aware of the presence of the seagull during her meditation. She replied, "I know the bird is there listening". We determined to do a guided imagery exercise asking the bird about spirituality. Alison closed her eyes and immediately saw ducks. Then she saw fish swimming around her. Suddenly she felt herself skimming along the water keeping pace with the seagull who, for the first time, was flying, low, and slowly, along the water keeping pace with her. She said excitedly, "the seagull is flying forward.. .really independent. Is not watching me but knows I am there. So there is trust there. He is really content." Eventually, I asked Alison if she could talk with the seagull. Alison reported that the seagull had landed at the edge of the water and they had sat on the beach to talk. Alison mused, "I think he is glad he got to move. This is the first time that I have really seen him as an individual. He felt I was with him when he was flying but we weren't as one. In the morning, when I meditate, we are one. We are getting closer now. I know that he is agreeing with what I have done today. I think it shows I have been doing my part." I asked Alison to ask the seagull what he knew about God. Alison giggled, "he says: questions, questions, questions... meaning that it is so much. He is amused. I can understand that he can explain but until I have the feelings for it, it wouldn't make any sense. Through the seagull I get the sense of comfort. So I talk to God, but at the same time I am getting the contact from the seagull. I think the seagull is more apt to be willing 128 to discuss right from wrong and stuff but when I talk directly to a God, I am asking for willingness and support; when I talk to the seagull, I am asking for comfort. I know as long as I keep doing this, I will get better understanding." I asked why the seagull was flying for the first time today. Alison reported, "I think that he didn't need to be so, so close at that moment. I was doing fine. So he went to get some fresh air and I could rely on myself so he knew that I didn't need that real desperate help." After Alison completed the imagery, we considered why ducks had appeared at first. Alison felt that it was the seagull's way of emphasizing that accessing him was not something that could be "taken for granted". We talked further about the seagull and Alison commented that, in fact, the seagull had always been with her, even in her childhood. She had used the seagull to take her away from her emotions. Alison reported feeling increased trust with the seagull.. "it was like knowing not to will things...they will just be there. And also you have to work for and respect what you get out of it. It's a relationship. It's there. It's always there. It's evolving with me." We talked about how Alison may be able to use her new found strength through the image of the seagull to deal with the challenge of communicating comfortably with her parents. Alison did a drawing (Figure A11.1) of a pink outline of a seagull "just like a silhouette..and it would work to protect both in giving words and receiving them." Alison also mentioned that her boyfriend had noticed a big difference in her. Ile felt she was more independent, had a stronger sense of self, and had more opinions about what to do as a couple. Alison talked about looking into the future. She said that when she used to do that, she felt really frightened, "it was like looking at a horror show." She did not feel that way anymore. She simple felt present. "I do take care of myself a lot more. It's lcinda neat. And I am not so picky anymore. What I tend not to do anymore is I don't tend to go back too much into the past. I'm too busy looking at today. The future I look at and it's blank. And today is just full of so much and it keeps me really occupied. And I am dog tired at the 129 end of each day. And I am sure I will get a little more vibrant when the body and myself becomes a little more accustomed to it. I sit there and go, 'this is so easy,' it's not, it's a lot of work.. .it's not easy, it's so natural." Therapist's log* session 11.  I felt heartened by Alison's steady progress. She had come to sessions in an increasingly energized and positive mood. I was also fascinated by her connection between the bird and God. Fish, for example, have traditionally symbolized Christianity. What was the meaning of the decoy ducks? Also, what did it mean that the seagull was finally flying, happily, freely? Had she attained a kind of spiritual independence? Figure A11.1. "The Seagull": Alison saw the pink silhouette of the seagull as a kind of beautiful screen which could act as both protection and safety without impeding a caring communication. She was very happy with the image. Session 12. December 10.  Alison began by declaring that life felt "more tiring" now for her than it was before our work together because before she used to be able to go into a cocoon. Now she felt she had to face life head on. Alison clarified, "the compulsion is still there but it's different because before I had no choice." Alison related the story of a recent dinner engagement wherein she employed her new found skills successfully. She did not respond as she would have a few weeks ago by binging, instead, she kept her cool. She was delighted with herself. Alison explained, "it was neat because I as I was driving I thought these are your opinions. Choices. And I knew I needed something that was comforting. Even I was shocking myself in the car at that thinking.., that I could make these choices! Before I wouldn't even have to think about it cause there was no choice. Now I have done it. It's ldnda like being safe.. .like 'you did do it once'." We talked about tools. Alison elaborated, "no matter what I say tomorrow I will get up and meditate. Before I do a binge I really do try to step back and go where am I. I 130 know there's that one tool of reaching out.. .that's a hard one for me. I am not that scared of the future any more. I think it's because I do know that there's going to be tough days and so it's ldnda like putting the good feelings into a bank account so that when the day comes that I need to draw on it, it will be there. The days are so full. They are so full. Before they were hollow days. It could have been a day with a huge agenda but it was still hollow. It's coming strictly from me. So that's why that complaining of the past is just not going to do any good anymore. It's so neat, it's like I'm this mini counsellor here!!! Instead of reading all those books, all that information is here. I see progress and I can see more coming and that's what's important. It's not stopping, it's going to continue." I asked Alison to redraw the TST drawings. She began with "How the world sees me" (Figure Al2.1). Alison drew carefully and said, "It's funny because it's not only how it sees me but whenever I think about how it sees me I also think about how I see the world. So it's a real balancing...it's not just me, me, me anymore." I ask about the tree..."before I just saw a neighbourhood. And now I am seeing details. And I will quickly go back to something that pleased me when I saw it. It's not like, boy, you don't deserve that so don't look. And I see myself a lot lighter.. .1 don't see dark clouds around me. Even if I am depressed. It's not black. It's a depression but it's not black. And the sea shows I am a lot calmer. I am sitting, I am not moving. I am really relaxed. Nothing is perfect but it's livable." Next, Alison drew a picture of "What I see when I look in the mirror" (Figure Al2.2). As she drew she explained, "I still see some flaws.., so I show my hair is not perfect. Body image is not great. But I am living with it. I am still wearing the bright colours. I am not hiding. So it's okay, boy, I'd love to see lots of improvement but for today I am going to live with what I have and have a good day." Finally, Alison drew a picture of "My Inner Healer" (Figure Al2.3). She declared, "I see the bird moving around but there's this outline of fish.. .in the real distance. When I imagine the fish.. .it's like seeing the bird here and there's a fish tank in front of it (the 131 brown is a symbol of that).. .1 don't believe in religion but I really believe in a spirituality...when I think about them and the way they spawn and the struggle. I really am overwhelmed. They know where to go. That's one of the wonders of the world. No matter what they are going to go through it. You see where they are plowing against all these rocks trying to go upstream. Especially salmon.. .1 can't eat salmon. And this time he is looking at me and he is all fluffed up. He is different from the seagulls that I see outside. Seagulls are black and grey. My seagull is not. It's funny I hate blue as a colour and I don't hate his colour. The blue says good, gentle...a colour that goes on forever and ever. It doesn't get darker or lighter and it's noticeable. He is content." Therapist's log, session 12. Alison's progress had been phenomenally fast. I suspected a destructive phase would eventually follow. I hoped that she had amassed enough tools that she could move through it relatively quickly. Figure Al2.1. "How the World sees Me": Initially Alison had felt compelled to leave this blank. This time, she had drawn a picture that had filled the page with colours and carefully rendered images: a tree, blue sky, a well-defined person perched on comfortably on the crest of a wave. Alison showed herself in pink and purple clothing suggesting a newborn spiritual awakening. The soles of her feet are together suggesting a kind of ongoing, self-sustaining energy. Figure Al2.2. "What I see when I look in the mirror": Alison had drawn a well- defined figure with arms outstretched and a smile on her face. She drew wild hair to show her comfort with not being perfect, or feeling that she had to be perfect. Figure Al2.3. "The Inner Healer": As with the first TST drawings, Alison drew a seagull. But this time she used very different colours - blues, yellows, and pinks - and this time the bird looked at the viewer very confidently. Also, Alison chose to symbolize the presence of fish in the picture. What could this mean about her sense of an integration with God? 132 Telephone debriefing, week six. Alison reported feeling good but was being careful to use "all the tools". She was feeling lonely inside but she was not binging. She said the decision not to binge brought rewards when she woke up in the mornings. She said she was giving herself permission to be "reasonable.., to trust in her own instincts and to remember to take care of herself." Follow-up Results Cynthia. When Cynthia and I saw each other again six weeks after the final session, she was in good spirits, had a job that she liked, and was regularly in contact with her sister from whom she had been estranged. Further, she had taken a big step in overcoming her concerns about intimacy in that she had made a decision to move in with her boyfriend. Also, Cynthia had determined that she wanted to continue therapy and had begun to see a therapist whom I had recommended to her. Cynthia felt that the work we had done together was the "best thing" she had ever done. Cynthia cited her trust in the therapy as a crucial component in her success. She appreciated that I believed her, "I had a feeling you really understood what it was like to be bulimic. And some of the things are gross, you can't just talk about that with anybody. Even though now, I don't have a problem with that anymore and I will tell anybody that I had an eating disorder." Cynthia felt during our work together she had learned a tremendous amount about herself. She explained, "it used to be that I didn't have any role models, I didn't have anyone that I could work things out with, I felt powerless to change things. But with you, it was so important that we spent the time to work things out. My understanding of people has changed. I have a lot more tools because I have been heard, and believed. I have basic needs like everyone else to be heard, and loved, and treated right, and given the space and dignity to recover from things and work things out." 133 With regard to the imagery component of our work Cynthia commented, "the drawing was okay, I could have worked harder, but I have feelings of shame around it that, that it wasn't going to be good enough. Sometimes I was more receptive because it was the only way I could get the stuff out!" Cynthia giggled. She continued, "the imagery was really.. .1 use that all the time now. I really believe in that. I don't ask people's opinion anymore. I realized that I have the answers inside of me. I realize I just need to stop, be still, and listen to it. I always have my little white light. That's where the answers lie. I have a lot more belief in myself. In some ways I have had to let go of my believes about people: that they knew more than I did and that they were better than me and they had better answers to my problems. I know that's not true anymore. I don't look at people now that they are better than me." Cynthia said that she had no desire at all to binge or purge anymore. She stated, "I'd rather cry, express emotion, than have to go into my room and be sick. It feels really good to not be acting out with an eating disorder!!!" Sonya. When I spoke to Sonya for the follow-up session, she had been taking anti- depressants for almost a month. She had gone to her doctor and had begun a course of treatment with him. She reported that the anti-depressants had, "taken the edge of blackness off. I feel better now than I've felt in my whole life." Prior to taking the anti-depressants, Sonya had been in a very black place. She was very depressed after our sessions had ended and she had continued to binge and spit as much as ever. At the time of our follow-up session, although she was feeling good, she was still having problems controlling her eating to her satisfaction. Reflecting back on our sessions, Sonya felt that she had "really learned a lot" from our work together. She felt that two main factors had contributed to her new insights: her trust in our therapeutic bond, and the use of guided imagery. Like Cynthia, Sonya had not responded strongly to the art therapy aspect of our sessions because she had felt a tremendous amount of shame around what she deemed to be her poor drawing ability. 134 With regard to the issue of trust, Sonya explained that, "I couldn't rattle you. You gave me a lot of room. You didn't run and you put up with my rages. For the first time I could scream and yell and not be afraid of my anger. I felt it was a safe place to scream. I never felt safe with my anger before." Sonya elaborated on what she felt she had learned about herself, "I learned I manipulate a lot. I learned about my fears - that what you feel about yourself is not necessarily who you are. I saw how self-centered I was and I learned I didn't have to take responsibility for everything. I now know that I am good person. I am not a bad person! And I have started to trust people more lately." Alison. When Alison and I met for the follow-up session, she was doing well: she was happy with her eating behavior, and she was in a good frame of mind. However, she had gone into a "rock bottom" tailspin after the Christmas holidays and it took her almost a month to regroup herself, remember the tools we had discovered, and decide to use them. Alison felt she had simply not done "any preparing for" the post-Christmas period. During that month she had, binged, and purged, and taken laxatives, all the while "observing" herself from afar. She felt that she had begun to binge again because, "I was kinda scared to let anybody down. I was doing so well, so well, and all of a sudden I couldn't hold it anymore. Shame kept me in the binge. Now, I can't do it for anybody but myself, on my terms. Nothing has anything to do with other people." Interestingly, Alison felt that when she had binged, the quality of binging had been different. She felt she had not tried to isolate half as much as she would have in the past. She did not, for example, push her boyfriend away. In reflecting back on the work we did Alison explained, "it's like I have a little textbook, and it shows me key things to do. But I did not want to open the textbook in January. I felt fear because I was starting to get better and it scared me. I am so scared I will not be able to keep it up. I am scared of being a normal human being. I felt I was getting smaller, there wasn't just me in the picture, there were all kinds of things all of a sudden. I lost control when I got better. It's being grown up. It's taking responsibility for 135 getting my life on the road and not having other people caretake for me. When I am healthy, my boyfriend and others didn't have to wonder and worry about me. So it's hard to leave that world behind. If I got better I wouldn't be the center anymore. And the days would go so easy. The feelings would just pass. I keep my feelings with me and feel them when I binge and purge. Now I am reclaiming my spirituality again. That belongs to me, not my parents. I can't believe how hard this is. It isn't the food. It's being responsible. It's going through the fear of being an adult. When I binge I am a little kid in a real silent rage at my parents." V. COMPARATIVE ANALYSIS OF THE CASES Two components comprised the descriptive framework developed to process and synthesize the results of all three case studies: "Aspects of ways of construing and experiencing" and "Patterns of Experience." Each of the thirteen aspects identified a salient unit of meaning, or theme which, when viewed together, served to create a 'portrait' of the bulimic woman's methods of perceiving her world. The patterns of experience was comprised of cycles of transformations which detailed a story of the healing journey of the bulimic experience. Aspects of Ways of Construing and Experiencing Fear of losing control leading to feelings of abandonment.  All three women exhibited an intense fear of losing control, i.e., of relationships, of levels of social support from friends and family, and of being acknowledged, which they perceived would lead to both being fat and, in turn, being abandoned. Cynthia was terrified, repulsed, and cryptically envious of fat people: "fat might be something that is contagious. And they are so out of control. And then I feel sorry for them because I think they must feel so awful about themselves. And it must be such a great shield to be that fat.. .it's a great way to keep the world out." 136 Sonya felt food controlled her completely,. "I do deprive myself constantly of food. I am frightened of it. Terrified of it. There is no question it has complete power over me. I am always thinking about how to get away from it. Not what to eat but what not to eat. If I let go of control I will eat until I blow up and I will be 300 pounds and I will be dead. My ego loves to make me eat.. .it's like HA HA...everytime I feel positive. I eat something and try not to be afraid of this...but it says 'yes you are. You are going to get fat.' And then I have to spit everything out. 'And if you get fat then you are not attractive therefore.. .you'll be alone, and afraid." Alison sighed, "I do go out of control with my food. I can't control my food. I try to control it. It's like I try to take control of everything, but for, some reason, in the end, it controls me more than anything... and when I binge, I isolate." The amount of body image distortion each woman experienced appeared to oscillate, depending on how she was feeling on a particular day. Sometimes, all three women felt they looked alright. Other times, Cynthia felt that her breasts were so big that she "needed to cut them off'; and both Sonya and Alison felt their bodies were "very, very fat". The use of bulimia as a protective shield. All three women used bulimia as a protective shield. Cynthia used binging "to hide from my feelings. If anything is on overload I eat. It's like fuck you HA HA. You can't touch me now. But the only thing is then I feel like an empty vessel having to fill myself up again because the only way I can protect myself is with food. And without it in my body I am totally vulnerable. If I puke and go work out, I am totally afraid... where if I have eaten and I don't throw up I feel ashamed and I feel fat but I don't feel like someone is going to attack me." Sonya saw bulimia as a shield, she binged especially when she felt her security was threatened in any way, which was often. She tenaciously fought the prospect of giving up her bulimic shield, "I keep saying I have been working real hard for years. I am working 137 hard at fighting everything that is coming my way. I know I am wrong but I am not fucking going to tell you that. I have worked very well at not getting well. It shows everybody that I am right. That I am the exception. It gets lots of attention. I don't even know if I wanna be well. It's too uncomfortable for me. It's too hard to stay happy. I don't know if I'll ever be able to break out. It's too much work." Alison used eating as a kind of protective shield to remove herself from the world. She felt she used bulimia to "isolate. I get really inward there. That's kind of my buddy, sort of. Just going inside myself. That's kind of like my best friend. I mean that's what I had to grow up with cause I really didn't have real close friends." Bulimia provided Alison with a shield when she "didn't want to deal with the feelings. I don't like people to see how hurt I can be." Finally, it provided Alison with protection from the guilty feelings of not doing anything, "I know binging just makes me not do anything. Like it is hard for me to turn around and say, I am really tired, mentally, or physically so just take the day off. I can't permit myself to do that so I binge. I can't have a normal day, I have to basically sort of relax and do nothing and eat." Interestingly, although they expressed an abhorrence of their bulimia, all three suggested this way of being was, in some ways, the only comfort they knew. And the prospects of losing the 'protection' of bulimia were, seemingly, unfathomable. Sonya was convinced that, in order to heal her bulimia, she would have to adopt a different kind of shield and become very fat. Alison felt she would become unbearably inconsequential, "I am scared of being a normal human being. I felt I was getting smaller, there wasn't just me in the picture, there were all kinds of things all of a sudden. I lost control when I got better. It's being grown up. It's taking responsibility for getting my life on the road and not having other people caretake for me." Cynthia felt that she "had to be small was so that I would not be completely alone"; to cast off the shield of bulimia was to risk becoming fat leading to a dreaded loneliness. 138 A desire to purify. All three women exhibited a desire to purify themselves of feelings of dirtiness, contamination through somehow being able to start anew. Cynthia felt mortified with the prospect of how she felt she was perceived, "I always think it's written all over my face.. .like all the awful things. And I always think I am really dirty and bad. I feel so dirty." She wrestled with the dirtiness she felt from memories of inappropriate sex, "I feel like I am contaminated. I am contaminated by their sperm, their bodies. They contaminate the air. They contaminate me everywhere I go. They look at me walking down the street I am contaminated. They ruin me." Sonya "hated" the contaminated feelings she felt when men looked at her in hungry, sexual way and yet she was devastated when they did not. Sonya and Cynthia's feelings may have been confounded by their sexual abuse experiences. I asked Alison how she felt when she was looked at by men. She frowned, "it would make me feel like I loathed myself. Like I need to hide me. Everything about me." Alison's feelings may have been confounded in that her first experience of a man was her father who abused her both psychologically and physically. All three women viewed the act of purging as a kind of internal scouring. Cynthia purged to cleanse herself of distasteful contamination and emotions. Sonya felt she wanted to rid herself of similar shameful qualities: "dirty, dirty and unclean and lower class. Stupid." Sonya took innumerable baths to cleanse and comfort herself as well. Alison felt she needed to purge to cleanse herself of, and to express, stuck emotions. She also attempted to purify and start anew by going shopping, "I will go on a shopping spree.. .clothes, records, it's ldnda like trying to get everything I can to put my life back. If I have everything I can start with a just perfect...of course it never works out but." Global and food-specific shame and guilt. All three women exhibited global and food-specific shame and guilt. All of the women felt global shame and guilt around their eating disorder and the resulting state of their "fat" bodies. Alison summarized all the women's feelings around food-specific shame and guilt when she said, "there's a lot of shame there over the food and the abuse of what I have done to my body." They all felt 139 global shame and guilt around expressing emotions that may hurt, or have hurt others. Cynthia was quite tearful around feeling guilty for having "embarrassed" her school counsellor in front of other students. She lamented, "I feel so ashamed." Cynthia also felt badly about taking care of herself. She did not feel she had a right to do so, "I did something for myself and it depresses me. There's a lot of guilt attached." Sonya felt a tremendous amount of shame around expressing herself through drawing to the point that she cried and was unable to continue. Alison felt enormous guilt around expressing her true emotions to her parents. She literally preferred to sacrifice herself rather than 'hurt' her parents, "I can't do it in front of them. I still have a lot of fear. And it's not fear of getting hurt now. But it is fear that.. .1 know my mom is trying the hardest she has ever tried to have a relationship and she is real sweet and everything but it's.. .and I know that once I tell her not to do it with the food that it'll hurt her she doesn't know any other way of doing this. She needed to leave something with me. I feel guilty if I don't eat them (the chocolates). She spent money on them." Cynthia and Sonya also felt shame and guilt around their families. Cynthia felt somehow responsible therefore shameful and guilty around her childhood sexual abuse issues, "I always think it's written all over my face...like all the awful things." Sonya felt incredible guilt around not having somehow helped her brother when her grandfather beat him, "I feel I shoulda done something." She felt deep shame around feeling like a lesser person than her sister, "she was perfect and I was a jerk. I felt ashamed." A sense of Godlessness. Throughout the course of treatment, each woman spontaneously referred to feelings of an inaccessible, hollow blackness within, and feelings of Godlessness. Of the blackness Cynthia stated, "sometimes I look in the mirror and I totally feel like all I can see is black. And other times I just see a person.. .like hollow." Sonya mused, "my ego is so huge. It's black. I love the colour, the non-colour black. I am so attracted to it instantly. Everything inside of me is black. Everything is buried. It's all black, just hollow black. I can't hear...whenever. ^I go inside, I can see the forest, but it's all 140 blackness... my head, stomach, heart.. .1 can only see emptiness and blackness. I don't feel things, I think them. It is almost impossible for me to feel anything." Sonya felt the blackness spoke of loneliness and abandonment. Alison said, "there's always such a black side to everything. I will look at the black side before I look at the positive. And I know that I would like to look at the positive but it is like, so hard to remember to keep doing that." All three women noted they loved to wear the colour black. And all three women appeared to be in some form of an unwilling symbiotic relationship with the blackness. Sonya articulated it this way: "I am not afraid of the darkness. I hate it but I feel sad for it. I want it to stop but I don't know what it is. I have hated it so much. I feel like it is not a part of me that is something else. It doesn't belong to me. It is another person inside of me. I haven't amalgamated with the blackness. It is another person controlling my life. I have to merge with it and be with it and love it. But I hate the blackness, I hate the blackness so much. It makes me eat. I know it does." The black hollowness seemed to happen in concert with a sense of spiritual lacking, or Godlessness. Cynthia described being on a bus when "this feeling came over me like I just said, 'God, you are the only one that can help me. This is something spiritual.' This is like a lack, right. There's no person. I am not asleep anymore it's like I can't explain this rationally because it isn't." During a guided imagery exercise Cynthia stated that her sense of spirit felt "like a breath. Like an uncontrollable thing. It wells up and wells up and it comes out and then I feel better for a couple of minutes and then it comes again. And I just feel so sorry for myself all the time. I am so sad. And I am all alone", she wept. She paused and added with a puzzled inflection in her voice, "I feel awful and I feel good." Sonya spoke dispassionately, "It's not life. I don't live. I just survive day to day. I am alive physically. Everything else is dead. Dead, dead, dead. I have no spirit. I have nothing. Everything about me is dead.. .it's all dead. Everything inside is dead. I have no 141 hope. I have nothing. I have no hope. I am too tired of trying to find it. I don't believe that there is a power that cares about me or that there's a power that wants me well." Sometimes Sonya did believe in a God. And when she did, she wanted to fight with God, bargain with God, "It's like if I give up my ego I am lost. I have lost the war. It's like do you want to be right or do you want to be happy? I have to be right. That means somebody will have one up on me. God... God will have one up on me. If I let go of control I will die because God doesn't care. I'll never be able to stop eating because I can't. If I let go of food, God won't take care of me and I will die. It's the ego.. .it's the evil in me. It's the satan...it's wants to kill me, it wants to keep me so unhappy so that the God part will not come through. It won't let go, it's afraid that if it does it will die. It's a spiritual illness." Depending on her state of mind, Alison felt a tremendous lack of God or she very much felt some kind of presence. She most clearly articulated this dichotomy when she spoke about how different she felt coming out of Alcoholics Anonymous meetings as opposed to emerging from Overeaters Anonymous meetings. When she came out of an OA meeting, she felt hollow, empty, depressed. "When I go to AA I come out knowing there is a God.. .there is something taking care of me. I can feel it. It's a definite feeling that I get. It's like something hugging me." For Alison, the concepts of spirituality and binging never existed together in the same moment. When Alison binged she just felt, "a big hole." When she felt spirituality she felt like, "there is no limit. It is like an eternity sort of." All three women also had an interesting relationship between their "inner healer" symbols and their sense of God. Cynthia reported that the light and God are different but that they are made of the same thing. She determined the light was closer, and was a pale blue colour. Sonya saw the wizard and God as different entities and yet they both possessed a "knowingness". Alison felt that the seagull and God complimented each other, "the bird protects me inside. And I think God is protecting me from the things outside of 142 me.. .1 will always be taken care of at work and things like this. The bird is going to protect my feelings." Self-doubt. None of the women in this study trusted their own perceptions of their worlds: their bodies, their judgment, their foundation. Cynthia flatly stated that, "I don't really use a mirror that much. I don't always trust what I am seeing. I know that sometimes what I think I see isn't really what's real because I have become distorted in my views." She felt that she was, "kind of fake. I feel like I am not real." Sonya did not even trust her own imagery let alone trusting reality. She was both drawn to, but extremely distrustful of the wizard. Similarly, with the Paul Bunyan tree exercise she exclaimed, "It's me, the tree is me!!! It's the grandiose performance tree. It's filled with lies, garbage, ego and fear, it's so huge because there is so much of it there.. ..full of crap. It's definitely me. I don't trust it." Alison was so doubting of her own perceptions that she was not even prepared to acknowledge her existence in the eyes of others. At the outset of treatment, when Alison was asked to draw her perception of how the world saw her, she left the paper blank. She declared "I don't think they see me, like I don't think I really matter. I try to think I do but I don't think anybody sees me so I don't see anybody really seeing me." Cynthia summarized the sentiments of all three women succinctly, "I am never believing myself. Because I am never on my side and I am always looking for THEM to validate me. I am relying on what they think of me, not what I think of me. I have abandoned myself." Feeling like a 'freak'.  All three women had a sense that they were different from others in an outcast sort of way: they felt like they were freaks. Cynthia proclaimed, "I am the one who is a freak. That's how I feel. Everyone else is over there and I am totally alone. I honestly feel like that.. .it's awful." Sonya felt she had medical proof to back up her beliefs: "I am not normal at all! Even my doctor said to me that I am a scientific phenomenon because everything I get is either backwards or weird or symptoms that no one has even had before. I feel like a freak anyway. So that just fits." Alison felt she could temporarily masquerade as a normal person but, in fact, she felt anything but normal, "I 143 can maybe get two good weeks of having a real normal life like normal people and then there will be that food stuff. Just hating myself and having absolutely no control. I mean, I manage to get up and go to work. I do that necessary stuff. I'll go to work. I'll pay the bills but everything else is screwed up." Opposing attitudes/desires on a single issue. Each of the women exhibited an extreme division in their thinking on a variety of major (attitudes) and minor (desires) fronts. Two examples of major issues involved their gender and their feelings about being bulimic: each professed an intense hatred of most, or at least certain men, and yet each was ashamed of, or frustrated with, being a woman; they all saw bulimia as horrifying and yet the prospect of getting well was, in some ways, terrifying. Minor individual issues also provided tormenting conundrums for each of the women. Cynthia desperately wanted to fit in with her peers and yet, "when I am fitting in, I don't want to be there, I want to break out. And then I can't get accepted." Sonya felt a deep desire to move nearer to the wizard, but when she contemplated movement, good turned to evil, "it's like everything I want, he is. But I can't, I am too afraid to trust." Alison, found herself immobilized by the opposing desires she felt: she loved her parents but she hated them; she wanted to do "good things" like exercise but she felt she had a small devil-like voice in her trying to make her do "bad things" like eat. She described the experience as feeling "split like two people". Self-pity. Self-pity was manifested by all three women in a direct form through outright declaration of self pity and in more vicarious forms such as feeling unacknowledged, or rejected, by others; and feelings of being a victim. Cynthia reflected, "that is what I feel is my eating disorder right there looking at me right in the eye. It's like the inability to assert myself in a way that will best suit me and bring out the best in me. I wanted to feel heard. I just wanted to feel acknowledged." And yet, she also felt extremely threatened when her self pity might be taken away from her through some real 144 acknowledgement, "It makes me really angry when people acknowledge me." Cynthia often cried and laughed at herself simultaneously declaring, "Total self-pity!!" And yet, Cynthia felt the "total self pity" she personified was a fait accompli because of her gender, "I feel like because I am a woman that I am a victim. The minute I was born, I was a victim. If I had been a man, they probably wouldn't have touched me. They probably would have fucked me up but they wouldn't have touched me. They wouldn't have used me." Sonya fought a similar battle, "I still feel like a victim. I still feel poor me a lot. I always play the victim, the hurt little puppy. The hurt girl." Sonya felt the prospect of acknowledgement from others, true acceptance, was beyond the realm of possibilities so she took offensive action, "I act defensive anyway so that I don't have to be hurt, so that I am already hurt, already rejected so I can't be rejected." For Alison, being "normal" was a form of rejection. She had always wanted to excel at something in school, and to be acknowledged for her excellence, but felt she never had done so. Alison felt that she dare not express her truth self, "I don't think they would ever really like who I was. They would always be disappointed no matter what. And I still try. I still try. But I can't do it." Alison wanted both her parents to acknowledge how they had physically and psychologically hurt her when she was a child. But she felt she would never be acknowledged for either the pain she had suffered or for who she was in the world, no matter what. So she used food to create a kind of acceptance, to alleviate the feelings of self pity for brief reprieve, "I use food to bring my emotions out...my feelings. While I am purging that's when I start to feel sorry for myself. But when I am eating, it's like I am feeling that fire." The comfort of self pity was deeply ingrained in Alison, during her recovery she noted somewhat longingly, "I am missing that self-pity. It gave me the reason to not turn around and do something. It was nurturing.., that's a good word. Like somebody hugging me." 145 Disenchantment with the perceived female role. Gender issues were a prominent unit of meaning among the three women. Volatile emotions around perceived female stereotypes, restricted opportunities for women, and concern over parental preferences for males were explicitly and implicitly expressed through the sessions. Cynthia stated resolutely, "I believe every woman has to like get out of the mold. Get out of what I have been taught. I don't have to wear dresses. I don't have to look this way. I don't have to act this way. I don't have to stick my fingers down my throat to express myself." She actively loathed women's lot in the world, "the minute they found out, that's a girl, I am owned. A boy is a man of his own, but a woman has to be owned by somebody. I NEVER wanted that." On many levels, Sonya wanted to be a man. She was pleased that "they call me the biker chick at work. Everybody calls me that. Cause I have a real toughness about me, a defense. And I am tough and smart. And I love male things." Sonya felt that to be a man was to have freedom, "the way I look at it, men don't spend their LIVES, like I have, wanting to be in a relationship. They get to do, they do things. They do stuff. They don't... girls sit around and wait for the fuckin' phone to ring to fall in love. Guys get to get out there and they have adventure and do things. You are born a man, you are born into power." Alison's confusion and fury over gender issues was less overt than was Cynthia's and Sonya's but it was as strong. She felt that her parents did not want her at all, but that things might have been better for her if she had been born a boy. She was extremely frustrated over the stereotyping which she perceived to be going on at her work wherein her boss always asked her to get coffee and her male co-worker was somehow able to eschew "grungy jobs that the women had to do". Further, virtually all the drawings Alison drew of herself during our sessions, looked like male figures (Figures 1.5, 2.1, 3.1, 3.2, 12.1, 12.2). The figures all wore pants, had no breasts, and had short, mannish looking hair (her hair was shoulder length) revealing a distinct denial of her female physical qualities. 146 Although each of the women openly professed, or alluded to a desire to be male at some level, they also expressed contempt, and hate for men. Cynthia snorted, "I could live in the world very easily without men. They are useless. It's hard for me not to be angry with men when I see what goes on in the world. And it's hard for me not to be angry when I know what happened to me. I feel repulsed by men. The look of them, the touch of them, their skin. The way they talk the way they move. Stupid, ugly people. Useless!" Sonya screamed, when it comes to sex, "I HATE MEN. I ABSOLUTELY HATE THEM." Alison, who lived and operated in a fairly closed, small world, curtailed her acerbic emotions to specific males with whom she associated: her father, and two men with whom she worked. Exceptional concern for the perceived down-trodden. During the course of treatment, each woman exhibited exceptional concern for those whom they perceived to be down-trodden. Cynthia was deeply moved by the plight of the transvestites. She wanted to help and support them in any way that she could, "you look at them and think, my God, they are freaks of nature. But on a spiritual level, it's like they are the strongest fighters in the world. To me, I see something in them. They will sacrifice opinion so they can feel like women. They are spit on and shunned, it AMAZES me!" Sonya wept and smiled as she talked about the joy she felt in helping the disabled group. She exclaimed, "all I care about in my life is making sure that people that feel different don't feel different. If that's all I could do in my life, that's what I want to do. I just don't want people who are different to feel bad about it." Alison felt a deep compassion for animals and exuded an overwhelming concern for their welfare. She worried about how the wild bunnies in Kitsilano Park lived. She talked about making every moment special for her bird, Caesar. She wept to the point of being unable to speak about the shepherd that she had seen die when she was a child. Alison fumed, "I just get really upset about how people can not really see that any type of animal is just, they got feelings. And I don't know how they live or how they feel or anything but they have their own lives and I don't like the way people will walk over anything to get on with their own lives. And that's a real hard issue for me. It has got its 147 own life and it has got its own way and it's happy and it's not affecting us? So it's like how can people... .1 just don't understand how people can be so cruel." The memory of an unsafe childhood.  Each of the women expressed memories of unsafe childhoods. Cynthia remembered being sexually abused by both her parents from a very young age. She lived her childhood on tenterhooks, "I could never depend on anything or anyone. I was always wondering what was going to happen next. I was always scared to death that I was going to say the wrong thing or do the wrong thing or be the wrong person so when I could get away with something I would completely just go for it because I knew that I was going to get it anyway." Sonya also remembered being sexually abused by a family member. She remembered watching her brother being severely beaten. She remembered constant poverty; never feeling like there was enough to go around. She said she "never felt safe or cared for." Alison spoke tentatively, and haltingly about how her parents abused her psychologically and physically; how they hit and kicked her, "but I was lucky. I never broke a bone or nothin'. I was never bad enough that I had to go to the hospital". Another aspect of childhood memories appeared to be distant and ambivalent relationships with siblings. Each of the women appeared to love, hate, and simply not care about their siblings. Cynthia sighed, "when I think of my sister.. .it's mostly just sad, just sad... sad, sad, sad. At four and a half I was taking care of my sister.. .my mom was sleeping. I resented her, I didn't know what to do with her. I didn't really like her that much...she was a tattle-tail." Sonya stated that she often binged when she went to her sister's house. She always felt that "she was perfect and I was a jerk. I felt ashamed." Over more than 14 hours conversation with Alison, she only spoke of her brother fleetingly three times. Each time she mentioned him was in response to a question I had asked her. Finally, all three women had childhood memories of detesting their parents. Cynthia started binging as a way to bleed her parents financially. She remembered vowing vehemently, "if it's the last thing I do I am going to suck those fuckers dry. But I couldn't 148 throw up yet because I didn't hate them enough. The first time I purged, I became crazy. And it never seemed like an eating problem." Sonya spoke contemptuously of the parade of her mother's boyfriends, and husbands, which she endured during her childhood. From an adult's perspective, she felt compassion for her mother's difficult plight. From her childhood perspective, she felt neglected. She spoke dreamily, and almost enviously of the proper upbringing to which she felt her niece and nephew were now privy. Alison wrestled with her hatred for her parents, "there's that part of me that just hates them. I hate them. But I mean they are old people. They are getting old and I know they did the best they could have done from what their childhood was like. When I see them, it's ldnda like I am looking at someone who doesn't have any face. And it hurts." Fear of intimacy. All three women feared the prospect of emotional intimacy. For Cynthia, "It is more frightening to be intimate with someone than to be anything else. When I look back and think about my life. Except for my parents, I never let anyone else care about me. So I don't really have any experience with people caring about me. After I left home, I never allowed anyone to care about me. If somebody was showing caring, I didn't like them anymore." Sonya virtually chanted a mantra of sorts that she would always end up alone because "there's nobody who can put up with me for long. I am not normal, I can't travel, I can't go in elevators, I am crazy around food, I am angry all the time. Spiteful, miserable, depressed. Nobody... .1 don't want anybody in my life." Sonya was terrified of getting in touch with herself in an intimate way, "cause I am afraid that all there is just pain and pain and more pain and that it will take forever to heal it. Cause that's all I have ever felt and I am just sick and tired of feeling pain and sadness and wanting to die. I'd rather stay in denial so I don't have to go through this. It's not worth it anymore to me so that I don't have to be hurt. To feel like dying all the time." Alison described a life of isolation and lack of intimacy. She described a real challenge in expressing intimacy, "It's like banging on a door. Let me out. Let me out of here. And all you have to do is open the door...let me out of here. Alison felt she was 149 never able to have close friends when she was a child because of her parents' issues around heritage. Emotional intimacy with her parents was out of the question, "I can't do it in front of them. I still have a lot of fear. And it's not fear of getting hurt now. But it is fear that.. .1 know my mom is trying". To Alison, expressing intimacy with her parents, even as an adult, represented a form of self-indulgence with the potential for hurtfulness. She never spoke of any close women friends. And, at 33, she was currently involved in her very first real relationship with a man. Even so, Alison was happy with him but she was afraid of herself; afraid that she would do something to jeopardize the relationship. She worried that she overdid things, i.e., making way too much food for a small party.. .over- compensating and taking too much control. Patterns of Experience Throughout the course of treatment, an overall pattern of experience among the women emerged. The women exhibited a cycle of transformation which documented their movement between two poles, from a place of sickness and great discomfort to a place of hope and an understanding of the possibilities of health. The transformation began in the destructive phase which depicted the manner in which the women existed on a daily basis. The women coped with existing in this phase through the channelling behavior of bulimia. As treatment progressed, each woman moved into a restorative drama phase of transformation: she experimented with the possibilities of change through oscillating between bulimic and non-bulimic states of being. The next phase, the transitional drama, saw the women testing out the new, unrecognizable world of comfort, stability, and health for longer periods of time. The results of the transformation revealed the final phase: a healthy place ostensibly the antithesis of the destructive phase. The destructive phase. Each of the women saw themselves as surviving life rather than actively living it. None felt they were existing anywhere near their potential. They all felt they were physically alive but spiritually dead. The women perceived themselves as absolute failures desperately wanting to change and yet feeling completely incapable of 150 doing so. For each of the women, the world was a black and white prison: they felt sentenced to an eternity in the blackness whilst being tortured by the sight of an unreachable vision of the white light. Channelling behavior.  All of the women had experimented with a number of methods by which to cope with existing in the destructive phase, especially through the use of alcohol and drugs. However, the bulimic behavior was the longest lasting and most virulent method. According to each of the women, abusive eating differed from the use of drugs and alcohol in that it offered, temporarily: feelings of extraordinary power and control; the ability to very effectively repulse society; the rewarding feelings of triumphant, secret defiance; the opportunity to cleanse and purify; a safe, protective shield from the world; a method by which to avoid horrific feelings of aloneness, abandonment and the accompanying fear through spending time with food as friend to fill up the black hollowness; it earned attention and highlighted a specialness; it enabled a kind of satisfying form of self-punishment, a kind of psychic suicide; and bulimia offered a method by which to buy some time-out, to have an 'excuse' to do nothing. The restorative drama phase. The timing of the inception of the restorative drama varied dramatically for each woman but the pattern was similar. It began with the expression and exploration of previously unaccessed emotions. The genesis of accessing these emotions began when the women were asked to reflect on their inner healing self. At that moment, each woman was able to stand back from her perception of reality to imagine what she could create in its stead. She considered the ingredients required to develop a support system conducive to her being able to exist in a healthier way in the world. Each woman began to fathom that she had an opportunity to take control of her emotions, to redirect her course in life, and to see the potential for fuelling herself from the inside rather than relying on the outside. This realization required some concrete thinking such as: how does one define and strengthen boundaries in order to feel safe to express oneself in the world? Once concrete goals were identified, each woman began to visualize how her 151 goals could be realized. Each woman began to gently experiment by using her newly discovered potential in real life situations such as standing up to an intimidating person and holding her own ground. The restorative drama very much represented a testing ground for each woman. She tested out new behavior and, like a two year old child exploring fresh territory, ran back to her 'mother' (binge eating) when things became too overwhelming. Then she would set out again, this time going a little bit further with a little bit more confidence before running back. And so the process unfolded. In order to leave the bulimic world, each woman had to develop a new fuel by which she could move through the world. For example, Cynthia stated clearly, "fear makes me eat, throw up, exercise, see my friends, fear of rejection, being unbeautiful, looking in the mirror". Changing to a new fuel of confidence and faith in herself required experimentation, making mistakes, courage, determination, and trust in the process. Trust in the process translated into what each of the women described as a "surrender" of needs to control. To surrender was an act fraught with fundamental meaning about survival in the world. Each of the women fought an important internal battle in this phase relating to surrender. Initially, for each of the women to surrender meant to lose, to figuratively die. The restorative drama occurred in each of the women in a very directive way. Through conversations with their inner healers during guided imagery exercises, each of the women was able to glean some very tangible guidance and suggestions for proceeding into a new, healthy world. Setting clearer boundaries, meditating, and using difficult experiences to learn in a bigger context were all examples of concrete suggestions cited by the women. Conversations with the inner healer appeared to dovetail with the development of a sense of personal spirituality which also appeared to be an important component in the 152 restorative drama. Each of the women was quite adamant in their sense of the difference between the inner healer and God. It was almost as though the inner healer was a personal angel which they felt was always in them, with them, and watching over them. They all perceived God to be an entity related more to the goings on of the external world around them. Alison articulated it this way, "it's like it protects me outside but the bird protects me inside. And I think God is protecting me from the things outside of me...I will always be taken care of at work and things like this. The bird is going to protect my feelings." The healing that was generated by various revelations, and then identified and embraced during the restorative drama also brought its own set of transition issues. All of the women reported a great amount of uncertainty and some discomfort over feeling well. They missed feeling self pity. They felt somewhat disoriented feeling happy. They felt overwhelmed at the prospect of actually feeling responsible for themselves without the safety of the protective shield that had been afforded by their bulimic behavior. The presence of transition issues ensured that the nature of the restorative drama was to and fro between the two poles rather than unidirectional. Each of the women regressed back to bulimic behavior at some point during the treatment even though things 'seemed' to be evolving positively. They appeared to need to acclimatize to wellness. Just as a victim of hypothermia can not be placed in a tub of hot water immediately, or a fasting person can not break a fast by gorging on a large meal, the bulimic women appeared to have a level of tolerance of foregoing their bulimic behavior with which they were comfortable. The more familiar they became with the new world of wellness, the longer they appeared to be able to exist in that world without requiring a visit to the darker, more familiar comfort of bulimia until finally they could let go of that world altogether. The transitional drama phase. For each of the women, the transitional drama was the result of much exploring and experimentation with new possible ways of living. It was the realization of courage summoned to deal with a somewhat frightening, unknown way of being in the world. Each of the women attempted to exist for substantial periods of time in 153 a world of non-bulimic behavior. They pondered what it would mean to be more emotionally intimate. They faced the fears of being well, of taking responsibility for their actions, and of being willing to accept the feelings of being out of control once in a while. Further, they all reflected that healing would take time, that it was a process of on-going growth and change. The growth and change had been reflected in the evolution of each of the women's symbols for their inner healers: Alison's seagull had evolved from sitting in the pit of her stomach with his back turned toward her into a happy bird flying along the water's edge; Sonya's inaccessible male wizard had transformed into a smiling open-armed girl wizard; and Cynthia's white light, which she had been depicted as a multi-coloured, straight-lined pyramid, had transformed into an amorphous, amoeba-type creature with a rainbow of colours including the flesh tones of a living person. Result of transformation. The results of the transformation for all three women were of an understanding of new options and choices available to them. The follow up sessions made it apparent that each of the women was still adjusting to adeptly, and comfortably being in a world of health. Each woman felt she was on an idiosyncratic road to health which she was confident she could follow. Cynthia grinned, "I feel like I have changed. It's like I am much more than just me. Its like there is a whole different person running around inside of there. It feels like God. It's like serenity." By the time we had finished the sessions, Sonya was not ready to stay healthy. Although she had managed to remain in a positive frame of mind for the fourth, fifth, and part of the sixth and final week of our work together, she had slipped back into full despondency and bulimia by the time our sessions ended. The experience did, however, impel her to seek anti-depressant medication treatment resulting in a greatly uplifted mood and moving her out of a constant state of suicidal ideation. Alison reported she was not feeling deprivation, but she was having difficulty with TRUST: that it would be okay; that her slight weight increase would not balloon but would stabilize into a new way of being. She was having trouble learning how much she should 154 eat for her size; developing a sense of what is actually appropriate for her in a normal, healthy way. She basically felt that life was "more tiring" now for her than it was when she was bulimic. Before she used to be able to go into a cocoon. Now she had to face life head on. She clarified, "The compulsion is still there but it's different because before I had no choice. Now I do." Summary of Transformations All three women experienced unique and yet similar manifestations of the first two phases of the cycle of transformation. Cynthia, Sonya, and Alison were each deeply ensconced in their respective destructive phases effectively channelled through the vehicle of bulimia. During the restorative drama, all three women experimented courageously with miniature cycles of restoration and decomposition through stopping their binging activities, exploring other ways of being in the world, then retreating back to the safety and comfort of bulimia only to rebuild again once they had regrouped. The courses of the three women began to substantially differentiate during the transitional drama phase. Specifically, Cynthia and Alison appeared to have firmly planted their feet in a new landscape of perceptions. They had learned how to use their inner healer in times of stress, for comfort, and for advice. They had experimented with asserting themselves in previously difficult situations using a concrete game plan. They were beginning to entertain the prospect of accepting their pasts, and taking on responsibility for their futures; they were beginning to trust themselves to make good choices in their lives. From an existential point of view, the two women had developed ontological courage. They also appeared to have developed a kind of personal spirituality which they were able to access on a regular basis. Sonya was not prepared to move as quickly into a different place for herself in the world. Sonya may need to spend considerably more time experimenting in the restorative drama phase before she feels comfortable moving onward. 155 VI. DISCUSSION Statement of Findings Thirteen themes were observed over the course of treatment with each of the three women. A theme may be characterized as "an element which occurs frequently in the text" (Van Manen, 1990, P. 78). Four themes in the study supported existing phenomenological research. They were: fear of losing control leading to feelings of abandonment; the use of bulimia as a protective shield; a desire to purify; and global and food-specific shame and guilt. Nine themes extended findings from previous research. They were: a sense of Godlessness, self-doubt, feeling like a freak, opposing attitudes/desires on a single issue, self-pity, disenchantment with the perceived female role, exceptional concern for the perceived down-trodden, the memory of an unsafe childhood, and fear of intimacy. Finally, an overall pattern of experience, the experiential structures that make up the bulimic woman's experience, was identified charting her journey toward healing. Limitations To begin, in considering the generalizability of the results based on the multiple- case studies detailed in this thesis, it is interesting to reflect on Yin's (1989) perspective. Yin argues that scientific knowledge is based on "a multiple set of experiments, which have replicated the same phenomenon under different conditions" (p. 21). He suggests further that, in reality the results of the experimental approach are more generalizable to theoretical propositions than to populations or universes. From this perspective, case studies may provide results that are just as valid as "true" experiments in that they too are generalizable or of relevance to the testing of theoretical propositions. This multiple-case study led to the identification of several themes which may serve as the basis for further exploration of these themes as theoretical propositions. 156 Only women were selected in an effort to control for possible gender differences. For example, Keeton, Cash and Brown (1990) suggest that men's experience of their body size and body dissatisfaction is significantly different from women. These results can not be extrapolated to bulimic men. Further, the age range was limited to 20 to 35 year olds in an attempt to control for potential confounds of generational differences in body perception. The experiences of bulimic teenage girls and older bulimic women may be substantially different from what was documented in this study. The choice of clients from the self-help group Overeaters Anonymous (OA) also created obvious restrictions with regard to the potential generalizability of results. The fact that the women who participated in this study were from OA meetings suggests a certain level of awareness about their disorder and a certain level of motivation to overcome it. It was likely the most motivated who self-select themselves to committing to this study. The potential for researcher bias existed in that one therapist conducted all therapy. Further, the therapist had been both bulimic and anorexic. Although the therapist's direct experience of eating disorders ensured a deep commitment and sensitivity to the study, that direct experience may also have represented strong opinions which could have functioned as blinders during data collection and analysis. Clearly, a fair amount of opportunity existed for researcher bias. This may be considered a marked weakness in the design which could compromise the validity of the study. However, as Yin (1989) points out, "internal validity is a concern only for casual or explanatory studies" (p. 43). This study was not attempting to explain but to clarify a theoretical portrait. Finally, in an effort to respond to individual differences in each client, no set number of drawings was required during each session. A difference in the number of drawings across clients may have contributed to a confound arising out of a lack of homogeneity of treatment. 157 Implications for Theory This section examines the findings of this study in relation to existing theory previously cited in the literature review in two parts. The first part explores how the major findings of this study have implications with regard to supporting, and extending existing theory. None of the major findings appeared to invalidate past research. Support of theory constituted the replication of that theory within and across each of the case studies. An extension of theory constituted the discovery, or honing, of findings which had not been cited in previous research. The section also identifies minor findings as they related to background information introduced in the literature review. Major findings. Many pieces of phenomenological research were supported by four units of meaning in this study. Fear of losing control leading to feelings of abandonment was a theme which dovetailed with, and validated, a fair amount of existing research. This finding substantiated discoveries suggesting that bulimic women seek control in a variety of ways including: the need to control self, others, and environment (including food) (Jones, 1989; Kramer, 1991; Patton, 1992; Worth, 1989). This finding also supported research (Herrington, 1991; Neufeld, 1983) suggesting female bulimics experience significantly more fear of rejection and loneliness. The unit of meaning which identified that bulimics use bulimia as a protective shield supported Swirsky's (1991) finding that bulimics use the binge/purge cycle defensively and Herrington's (1991) findings that bulimics use the cycle to isolate. The unit of meaning of global and food-specific shame and guilt supported the existing research of Frank (1989), Neufeld (1983), and Reynolds (1991). Finally, the theme of a desire to purify was directly identified in Neufeld's research. Indirectly, this unit was cited in Reynold's observations that bulimic women embrace feelings of contamination and self-disgust and in Hsu's (1990) research which suggested that bulimic women often feel dirtiness in the early stages of a binge. Nine of the findings appeared to be extensions of existing research. The theme of feeling like a freak, moved beyond Grissett's (1991) observations of the bulimic's self- 158 perceptions of social incompetence in that the women in this study did not simply feel awkward in many social situations, they felt like repulsive outcasts. Tryniecki's (1991) observations that the bulimic woman's global self-concept is significantly lower than that of a non-bulimic woman's appears to be more pointedly manifested through the theme of sdf- pity. The theme of opposing attitudes/desires on a single issue was prominent in all three women as well. This finding extended research through recognizing that the combination of various existing findings points to the presence of a clash of attitudes and desires in bulimic women. For example, Kramer (1991) found bulimic women were more likely to be involved in dependent, enmeshed intimate relationships while Worth (1989) found the issue of separation and the creation of an autonomous sense of self to be a pivotal concern. This study extended the findings of Printz's (1989) observations that women did not identify with the traditional feminine role. The theme of disenchantment with the perceived feminine role furthered that finding through suggesting that, at times, each of the women fantasized about being a male. Of all the phenomenological research to date, Neufeld's (1983) work appears to have travelled the most similar ground to that covered in this study. Her observations represent the foundations of several themes charted in the descriptive framework. These findings seem to have honed her work into more specific descriptions of how her themes might manifest. Neufeld's theme of being-for-others is specifically expressed in the theme of exceptional concern for the perceived down-trodden. Neufeld's theme of fear of fear of relationships is clarified through the unit of meaning of fear of intimacy by citing the specific element of what is feared about relationships. The theme of self-doubt furthers Neufeld's (1983) theme of invalidation of perceptions in that this finding suggests an even deeper experience of negation in the bulimic woman moving from an external to an internal focus. Neufeld's theme of sense of obliviousness and depersonalization of self was extended through the theme of a sense of Godlessness through moving from a sense of emptiness into specifically recognizing the nature of the emptiness. Finally, Neufeld's 159 theme of fear of separation may be connected to the theme of a memory of an unsafe childhood. This connection however, seems to be more of a parallel one. The theme of memories of an unsafe childhood and the fear of separation appear to be complimentary components in that they may both be perceived as impasses to both the successful completion of childhood and the successful transition into adulthood. The other component of the descriptive framework was: the story of the pattern of experience which also appears to be an extension of theory. Although Hsu (1990) has conducted research following the binge-vomit cycle, this study appears to be the first foray into exploring the larger cycle of the bulimic journey toward recovery and healing. A common orientation. In reflecting on the coherence of the thirteen themes, how might they come together to embody a single orientation? The common element from which all of these themes appear to emanate is the bulimic's core belief that they are fundamentally flawed. This belief manifests itself in the form of the thirteen themes. The following paragraphs represent a speculative effort to understand how the themes may, in fact, be different expressions of one fundamental orientation. The four findings in the study which validated existing phenomenological research can all be reflected upon as attempts by the bulimic to avoid the exposure of their fundamentally flawed being. The fear of losing control leading to abandonment appears to be directly linked to the fear of being exposed: the bulimic woman believes that if she does not stay in control of herself, her environment, and especially her food, she will become fat which will lead to rejection. The use of bulimia as a protective shield appears to function as a method by which to avoid having their perceived 'flaw' discovered through creating isolation. The desire to purify appears linked to the feeling that if the bulimic could somehow 'start again' then the flaw could be removed, leaving perfection in its stead. Global and food-specific shame and guilt seem to be the result of the bulimic woman's sense that she is unable to totally purify herself for any length of time. Because the bulimic 160 is flawed, the consequence of that may justify in her mind why she 'deserves' to be, and feel, isolated. The nine themes which extended findings from previous research can also be viewed within the common orientation of being flawed. A sense of Godlessness may be related to bulimics' inability to access or experience unconditional love in any way: they are internally insulated from even themselves. Similarly, self-doubt may be viewed as another manifestation of a lack of self-acceptance. The theme of feeling like a freak shores up the bulimic's belief that she is flawed, and, by definition, deserves to be isolated from everyone else in the world. The presence of self-pity appears to function as a 'friend' of sorts. That is, 'if I am going to be isolated because I am fundamentally flawed at least I can comfort myself with a familiar feeling'. Disenchantment with the perceived female role leads to further feelings of alienation in that bulimic women do not even feel that they resonant with a group with which they 'should' somehow connect: their gender. Wooley and Kearney-Cooke might suggest that this theme is ultimately "traceable to problems in the construction of womanhood" (p. 479). Exceptional concern for the perceived down-trodden is a theme which appears to evolve out of a feeling of simpatico with other 'freaks'. Yet a connection with other 'freaks' does not in anyway undermine the sense of being alone in that a 'freak' is, by definition, unique and therefore must suffer their unique flaw in isolation. The theme of a memory of an unsafe childhood further substantiates the presence of an immutable flaw in that bulimic women appear to have seen themselves as profoundly different from others even as children. The theme of fear of intimacy dovetails into the fundamental flaw: if a relationship becomes too close, the bulimic will be found out and rejected accordingly. The connection between the theme of fear of intimacy and isolation may initially seem a bit confusing: if a person is terrified of isolation, why would they not covet the opportunity for intimacy? It may be that the thought of intimacy is one of the most frightening prospects a bulimic could 161 face in that the fear of rejection leading to a sense of isolation may be amplified tenfold: the larger the stakes, the greater the opportunity for heart-piercing pain. The theme of opposing attitudes and desires on a single issue underscores the push- pull conundrum in which bulimics appear to live their lives: they desire intimacy with themselves and others more than anything but that need may make the prospect of failure too frightening. Root, Fallon, and Friedrich (1986) point to a number of sociocultural contributions which may lead to, or exacerbate, this theme such as the negative labelling which seems to occur whether a woman is direct or indirect in expressing her anger. The pattern of experience can also be considered in light of the bulimic woman's conviction that she possesses a fundamental flaw. It followed the bulimic woman's movement between two poles: from a place of profound near-death sickness to a desire to firmly grasp and live life. The healing journey was not so much the ability to irradicate the perceived flaw as it may have been learning to accept her flaw and to love herself, flaw and all. Minor findings. Other phenomenological findings in this study were only applicable to one, or sometimes two, of the three women. What follows is a reflection on those findings in light of existing research cited in the literature review. As with the phenomenological research, many of the discoveries made in this study support existing research. Printz's (1989) findings, regarding bulimic feelings of being unable to live up to the expectations of parents, were really only relevant in the case of Alison. With regard to biological factors, Sonya's case may be relevant. In particular, Bendfeldt-Zachrisson (1992) noted a possible common etiology between bulimia and affective disorders which may have been present in Sonya. Throughout our sessions, Sonya exhibited mercurial mood swings. At the end of our work together, I suggested that Sonya 162 consider anti-depressants. When we met six weeks later, she had been taking anti- depressants for a full month and reported feeling the best she had ever felt in her life. Familial relationships, in one form or another, appeared to have been a factor in the bulimic experience in all three cases. Cynthia, Sonya, and Alison all reported varying degrees of difficulty with boundaries, conflict management, and support for autonomy as cited by Connors and Morse (1993). All three women appeared to perceive inadequate social support from both friends and family (Grissett, 1991). With regard to the effect of sibling relationships (Lewis, 1988), Sonya and Cynthia both expressed envy of their sisters seemingly better grasp of life although they did not appear to exhibit jealousy to the point of their daily functions being impeded. Sexual abuse was another consideration cited in the literature. It was present in two of the three cases in this study. Both Sonya and Cynthia, who were sexually abused, binged more frequently than did Alison, who was not sexually abused, as Waller (1992) had suggested would be the case. Zerbe's (1992) observations were also corroborated by Sonya and Cynthia in that they both responded to their childhood sexual trauma with sexual promiscuity in adulthood. In considering body image, all three women were resolute in their desire for a socially sanctioned thin body (Wiseman, 1992). All three definitely overestimated the size of their bodies (Cooper & Taylor, 1988) and were intensely afraid of obesity (Powers & Schulman, 1987). Locus of control appeared to be a factor for all three women as well. They all exhibited strong tendencies to put a great deal of importance on what other people thought above and beyond their own opinions, judgment and intuitions, as Shisslak and Pazda (1990) observed to be the case for bulimic women. Other findings did not appear to be supported at all by this study. Tennessen (1991) suggested that bulimic women were less satisfied with their achievements. The anti-thesis of those findings as observed in this study. Each of the women appeared to be very pleased 163 with themselves whenever they accomplished anything deemed of merit. For example, they all appeared very pleased with themselves when they discovered their abilities to access internal images. Also, some findings simply felt murky and confusing in relation to the discoveries made in this study. Specifically, Igoin-Apfelbaum (1985) suggested that bulimic patients have symbiotic feelings for their mothers with whom they experience "shared inescapable distress" (p. 164). Igoin-Apfelbaum was referring to the bulimic woman's biological mother but if one subscribes to the ideas of Woodman (1982) and others, the 'mother' may be a partially literal, partially figurative symbol of a life force. Implications for Practice Given that less than 50% of practicing clinicians who specialize in eating disorders believe that a consensus regarding treatment has been reached (Herzog et. al., 1992), an openness to the findings and potential implications for therapy cited in this study may well lead to additional insights and advancements in treatment practice. In practice, the most successful therapies to date, cognitive-behavioral therapy, group therapy (Herzog et. al., 1992) or any other therapeutic approach may benefit from an awareness of, and sensitivity to, the nature of the bulimic experience as mapped out in the descriptive framework. For any approach, the 13 themes may be most useful if viewed as an interconnected. Recognition, acceptance, and exploration of these themes on the part of the therapist may help to facilitate the experience of a deeper therapeutic bond, an opportunity for greater insight, and a sense of feeling profoundly understood on the part of the bulimic client. The second major implication for practice is in the observation of a pattern of experience suggesting a method by which to identify a bulimic's stage of recovery. The ability to identify a bulimic's phase in their pattern of experience, may afford the clinician, regardless of their chosen therapeutic paradigm, more options and more accuracy in terms of selecting the most effective treatment approach. For example, a clinician who begins working with a bulimic woman may chose to work differently with her if they know that she is in a destructive mode of the cycle of the restorative drama phase as opposed to simply 164 the destructive phase. Those two situations may, on the surface, manifest in an identical way. However, if the clinician is aware that the client has also experienced the restorative component of the restorative drama phase, they can attempt to access the memory of that healing experience and work with the client accordingly. The above scenario suggests that an awareness of the pattern of experience may help to identify a system by which the clinician can more accurately assess the state of the bulimic client thereby providing an opportunity for more focussed treatment plan. Implications for Future Research There may be several future possibilities for continued research to be developed from the information uncovered in this work. First, a replication of this treatment program may be warranted in order to test the stability of the thirteen themes, the pattern of experience, and the possibility of a common orientation of isolation mapped out in this study. Second, different methods of exploring the findings of this study may be useful. A survey method, for example, may be an effective format in which to validate the study's findings. Third, an expanded, and varied sample could be considered including a larger number of participants, a broader age range of participants, a separate study on bulimic men, and the inclusion of bulimic individuals from sources other than 0.A.. Fourth, it is possible that a longer treatment period could enhance the depth and breadth of insight garnered. For example, how might the cycle of the pattern of experience develop over a longer period of time? Fifth, this study both validated, and extended the expression of imagery work of both Miller (1991) and Hill (1992). All three women were slightly, or very, uncomfortable with drawing sometimes or all the time; although all acknowledged that drawing had been an effective way of expressing some difficult-to-express feelings. However, the guided imagery was appreciated unequivocally throughout the session work. In fact, during the follow up session each woman spontaneously volunteered positive comments about the ongoing benefits experienced on a daily basis as a result of having participated in the 165 imagery exercises. Each woman alluded to her personal inner healer symbol as something from which she was regularly able to garner internal strength. The success of the guided imagery exercises suggests future research into the use of guided imagery as a adjunctive method by which to understand and treat bulimics may be very fruitful. Sixth, this thesis did not extensively explore sexuality as it may effect bulimic women. Pope (1992) found no differences in reports of childhood sexual abuse in bulimics versus the general population. However, Thackwray (1991) has suggested that the 49% of bulimic women who do report histories of sexual abuse may still be underrepresenting the actual number of sexually abused bulimics. Further specific research into the experience of bulimic women and sexual issues may render some useful data such as developing a more definitive understanding of the role sexual abuse may play in the bulimic experience. Finally, there are many implications for future research when bulimia is viewed through the kaleidoscope of sociology. These research findings offer an opportunity to add to an ever-growing speculative discussion about how bulimia may be viewed within a larger societal context. The following few paragraphs explore the themes discovered in this study with questions and speculative comments which could lead to intriguing pieces of future research. A disenchantment of the perceived female role may have been a way to freeze or immobilize the perceived obvious and subtle inequities in the bulimic women's worlds. In conscious, and subconscious ways, the women in this study abhorred and resented the indelible stamp of 'second sex' they felt was printed on their foreheads. Changing the shape of their female bodies through eating was one way to blur the mark of that stamp. Sonia Johnson (1987) maintains that the bulimic woman's sense of Godlessness is directly connected to her issues around gender roles. She feels that God and men are in an Old Boy's Club together and that as long as "God is male, the male is God" (p. 5). Women, by that definition, must always be "outside (of the club) with our faces pressed up against 166 the glass" (p. 4). Or a sense of Godlessness may be sparked by other influences. Is this theme indicative of a general societal dearth of spirit? Maybe the binge/purge cycle is a desperate attempt to feed the "hollow blackness" of a starved spirit within the confines of an advanced capitalistic society's narrow vision of perfection. Maybe bulimia is, in fact, a healthy reaction to a reality wherein one feels ostracized if one is not unnaturally slim but one feels completely compromised by succumbing to dogma if one is unnaturally slim. It was intriguing that each of the women felt that to surrender to healing meant to become fat. It was as though they could not conceive of a middle ground: to embrace health and spirit within was to forego the fight for the attainment of 'beauty' in the eyes of society. The inability to walk a middle ground appears to connect with the presence of opposing desires on a single issue. The 'damned-if-you-do-damned-if-you-don't' conundrum seems to permeate many facets of the bulimic's life. The bulimic woman appears to possess an enormous fear of being abandoned while simultaneously being terrified by the prospect of intimacy. She condemned herself as a worthless "freak" and yet appreciated the inner richness of the down-trodden "freaks" of society above any other people. She doubted her own perceptions and yet the prospect of surrendering any vestige of control she felt she did have to another was untenable. It was as though this conundrum was an elegant way to remain frozen, ironically, in the hollow blackness she abhorred yet knew so well. Perhaps it was the only solution she could conceive of to feel somewhat safe. At least, in that frozen place between life and death, a half opened coffin of sorts, one may be able to ferret out strangely dependable comforts. For example, Alison described her self-pity as a kind of friend when she felt no one else was around, "it's like somebody hugging me." The presence of opposing desires may account somewhat for the theme of exceptional concern for the perceived down-trodden. Wooley and Kearney-Cooke (1986) suggest that the bulimic woman is "forced to chose between the victim (the down-trodden) and the victimizer" (p. 480) and understands both roles well. Perhaps enabling, supporting, and attempting to better the lives of the perceived down-trodden might afford some release 167 of the bulimic woman's own self-perceived oppression during the moments in which she is providing help to others in whom she can see facets of herself. It is possible that the bulimic woman can access, and have deep compassion for, the ostracized, unchampioned part of herself through her concern for the down-trodden. What may appear to be disproportionate concern for various perceived down- trodden in the eyes of others could very well be the only way a bulimic woman is able to provide tenderness and love to herself. Altruism, albeit selective, may well be a way to experience a kind of communal belonging that otherwise goes unnurtured in the bulimic heart. Many would argue that, on the whole, North American society has retreated from charitable work at the grassroots, community level over the past two decades. Perhaps there is a correlation between the overall level of communal interaction and caring and the North American explosion of bulimic behavior. Many would also argue that a sense of family, literally, and communally, is an integral part of a feeling of safety in childhood. The dearth of that perception may lead to a further erosion of being able to learn about and trust both the experience of intimacy and self-perceptions. As generations coming of age in the atomic age, perhaps nothing in childhood feels completely 'safe' or completely pure, anymore. Perhaps the global shame and guilt harboured by bulimics along with their desire to purify is a response to a global environmental problem as much as it could be responding to a more personal crisis. But, if that were the case, why are 95% (Wolf, 1990) of bulimics women? It may be that, as Woodman (1982) has observed, "the experience of the feminine is the psychological key to both the sickness of our time and its healing" (p. 132). Sonia Johnson (1987) suggests that exploration of the female experience may lead to a new global consciousness thereby setting up "a new morphogenetic field, a new blueprint for form and behavior" (p. 159). How might the bulimic experience be contributing to this new blueprint? Clearly, the themes cited in this study have the potential to give rise to numerous questions, and much more research pursuing a broad spectrum of possibilities. Further, the 168 speculative discussion suggesting a common orientation of a fundamental flaw also generates ideas for research which may reach beyond the scope of eating disorders into other addictive behaviors. For example, are the themes identified in this study relevant to other populations such as alcoholics or substance abusers? Summary Four findings in the study supported existing phenomenological research. They were: fear of losing control leading to feelings of abandonment; the use of bulimia as a protective shield; a desire to purify; and global and food-specific shame and guilt. Nine themes extended findings from previous research. They were: a sense of Godlessness, self- doubt, feeling like a 'freak', opposing attitudes on a single issue, self-pity, disenchantment with the perceived female role, exceptional concern for the perceived down-trodden, the memory of an unsafe childhood, and fear of intimacy. A final finding related to the charting of an overall pattern of experience of the bulimic woman's journey of healing. The use of imagery was also reported as an exceptionally beneficial and effective tool for gleaning insight into the bulimic experience across all three case studies. As a corollary of the discovery of those insights two of the three women were well on their way to overcoming bulimic behavior when the follow up sessions were conducted. The third woman used her new self-knowledge to enable a decision regarding the commencement of a course of anti-depressant medication which resulted in a very positive change in her general mood. 169 References Achterberg, J. (1985). Imagery in healing: Shamanism and modern medicine.  Boston: Shambhla Publications. Agras, S. (1987). Eating disorder: Management of obesity. bulimia. and anorexia nervosa. New York: Pergamon Press. Allan, J., & Clark, M. (1983). Directed art counselling: An intervention for primary children. Elementary School Guidance and Counseling. Allan, J. (1978). Serial drawing: A therapeutic approach with young children. Canadian Counsellor, 12, 223-228. Amari, D. (1986). The use of clay to form potential space with a bulimic patient. Pratt Institute Creative Arts Therapy Review, 7, 13-21. American Psychiatric Association (1987). Diagnostic and Statistical Manual of Mental Disorders (3rd ed. revised). Washington, DC: American Psychiatric Association. Arkowitz, H. (1989). From behavior change to insight.  Journal of Integrative & Eclectic Psychotherapy, ,V3), 222-232. Belt, J. R. (1990). Parenting styles associated with eating disorders.  Dissertation Abstracts International, 52, 1707B. Benassi, V., & Sweeney, P. (1988). Is there a relation between locus of control orientation and depression? Journal of Abnormal Psychology, 97(3), 357-367. Bendfeldt-Zachrisson, F. (1992). The causality of bulimia nervosa: An overview and social critique.  International Journal of Mental Health, 21(1), 57-82. Berkowitz, S. (1990). Art therapy with a Vietnam veteran who has post traumatic stress disorder. Pratt Institute Creative Arts Therapy Review,  11, 47-62. BosIdnd-Lodahl, M. (1976). Cinderella's step sisters: A feminist perspective on anorexia nervosa and bulimia. Signs: Journal of Women in Culture and Society,  2(2), 342. Bronfenbrenner, U. (1979).  The ecology of human development. Cambridge, MA: Harvard University Press. Buck, J. (1948). The H-T-P test. Journal of Clinical Psychology, 4, 151-159. Bulik C. M. (1992). Abuse of drugs associated with eating disorders. Journal of Substance Abuse, 4(1), 69-90. Campbell, C. (1990). Art therapy with a masochistic adolescent. Pratt Institute Creative Arts Review, 11, 1-12. Campbell, D., & Stanley, J. (1966). Experimental and Quasi-experimental Designs for Research. Chicago: Rand McNally College Publishing Company. Conn, S. E. (1991). Art therapy as a psychiatric counseling modality in the treatment of the hospitalized bulimic. MAI, 29, 490. 170 Connors, M. E., & Morse, W. (1993). Sexual abuse and eating disorders: A review. International Journal of Eating Disorders, 13(1), 1-11. Cooper, M. J., & Fairburn, C. G. (1992). Thoughts about eating, weight and shape in anorexia nervosa and bulimia nervosa. Behaviour Research and Therapy, 30(5), 501- 511 Cooper, P., & Taylor, M. (1988). Body image disturbance in bulimia nervosa. British Journal of Psychiatry,  153(Suppl 2), 32-36. Edwards, D. (1990). Cognitive therapy and the restructuring of early memories through guided imagery. Journal of Cognitive Psychotherapy, 4(1), 33-50. Egan, G. (1990). The skilled helper: A systematic approach to effective helping  (4th ed.). Pacific Grove: Brooks/Cole Publishing Company. Fairburn C. G., & Begfin S. J. (1990). Studies of the epidemiology of bulimia nervosa. American Journal of Psychiatry 147(4), 401-408. Fairburn, C. (1981). A cognitive-behavioral approach to the treatment of bulimia. Psychological Medicine,  11, 707-711. Fan, C. (1990). A study of the guided imagery process: Awareness and the discovery of personal meaning. Canadian Journal of Counselling, 24(1), 45-52. Feinberg-Moss, B., & Oatley, K. (1990). Guided imagery in brief psychodynamic therapy: Outcome and process. British Journal of Medical Psychology,  0(2), 117-129. Ford, K. A. (1985). The heterogeneity of bulimia.  Dissertation Abstracts International, 46, 4397B. Fornari, V., Kaplan, M., Sandberg, D. E., Matthews, M., Skolnick, N., & Katz, J. L. (1992). Depressive and anxiety disorders in anorexia nervosa and bulimia nervosa. International Journal of Eating Disorders, 12(1), 21-29. Frank, E. S. (1989). Shame and guilt in eating disorders. Dissertation Abstracts International, 59_, 3896A. Frye, B. (1990). Art and multiple personality disorder: An expressive framework for occupational therapy. American Journal of Occupational Therapy,  44(11), 1013-1022. Gehr, P. (1989). Guided imagery as a treatment for depression. Dissertation Abstracts International, 50(2-B), 746. Gibson, M. L. (1991). Treating bulimics: The use of imagery to heal.  Manuscript submitted for publication. Grace, P. S. (1990). Personality characteristics of the mother of bulimics. Dissertation Abstracts International, 51, 1497B. Grissett, N. I. (1991). Perceived social support, social skills and quality of relationships in bulimic women.  Dissertation Abstracts International,  52, 5534B. Guidano, V. F., & Liotti, G. (1983). Cognitive processes and emotional disorders: A structural approach to psychotherapy.  New York: The Guilford Press. 171 Hart, K., & 011endick, T. (1985). Prevalence of bulimia in working and university women. American Journal of Psychiatry,  142(7), 851-854. Hartmann, A., Herzog, T., & Drinkmann, A. (1992). Psychotherapy of bulimia nervosa: What is effective? A meta-analysis. Journal of Psychosomatic Research,  36(2), 159-167. Hathaway-Clark, C. (1991). An exploration of the father-daughter relationship and its contribution to bulimic symptomatology. Dissertation Abstracts International,  52, 6085B. Herrington, G. A. (1991). The experience of being bulimic as revealed through the binge episode: An existential-phenomenological investigation. Dissertation Abstracts International, 52, 3294B. Herzog, D. B., Keller, M. B., Strober, M., Yeh, C., & Pal, S. (1992). International Journal of Eating Disorders, 12(2), 215-220. Hill, L. (1992). Fairy tales: Visions for problem resolution in eating disorders. Journal of Counselling and Development, 70, 584-587. Holden-Lund, C. (1988). Effects of relaxation with guided imagery on surgical stress and wound healing. Research in Nursing and Health, 11(4), 235-244. Horowitz, M. (1970). Image formation and psychotherapy.  New York: Jason Aronson, Inc. Howe-Murphy, R. L. (1987). Use of imagery supported by a conditioned stimulus to affect perceived control, self-efficacy and bulimic behaviors of university women. Dissertation Abstracts International, 49, 3443B. Hsu, L. K., & Sobkiewicz, T. (1991). Body image disturbance: Time to abandon the concept for eating disorder? International Journal of Eating Disorders,  10(1), 15-30. Hsu, L. K. (1990). Experiential aspects of bulimia nervosa. Behavior Modifications, 14(1), 50-65. Igoin-Apfelbaum, L. (1985). Characteristics of family background in bulimia. Psychotherapy and Psychosomatics, 43, 161-167. Johnson, S. (1987). Going out of our minds: The metaphysics of liberation.  Freedom, CA: The Crossing Press. Jones, D. A. K. (1989). A naturalistic inquiry of women expressing symptoms of bulimia nervosa. Dissertation Abstracts International,  50, 3156A. Keck, P. E., Pope, H. G., Hudson, J. I., McElroy, S. L., Yurgelun-Todd, D., 8c Hundert, E. M. (1990). A controlled study of phenomenology and family history in outpatients with bulimia nervosa. Comprehensive Psychiatry, 31(4), 275-283. Keeton, W., Cash, T., & Brown, T. (1990). Body image or body images? Comparative, multidimensional assessment among college students. Journal of Personality Assessment, 54, 1. Kolb, C. (1975). Disturbances of body image. In American Handbook of Psychiatry (Vol. 4). New York: Basic Books. 172 Kramer, R. J. (1991). Separation-Individuation pathology, intimacy capacity, and social adjustment in bulimic and non-bulimic women. Dissertation Abstracts International, 52, 3908B. Lacey, J., & Birtchnell, S. (1986). Body image and its disturbance. Journal of Psychosomatic Research,  30, 6. Lacey, J. (1983). Bulimia nervosa, binge eating and psychogenic vomiting: A controlled treatment study and long-term outcome. British Journal of Psychiatry, 286, 1609-1612. Lavallee, P. A. (1987). Religiosity, rituals and patterns in anorexic and bulimic families. Dissertation Abstracts International, 47, 4654B. Leclair, N. (1984). Locus of control and nonverbal decoding accuracy among women with bulimia. Dissertations Abstracts International, 45, 1643A. Lee, N., & Rush, J. (1985). Bulimia and Depression. Journal of Affective Disorders,  2(3), 231-238. Lewis, K. G. (1988). The sibling relationships of bulimic women. Dissertation Abstracts International, 49, 2157A. Macks, R. (1990). Clay as a healing medium for anorexia and bulimic clients. Pratt Institute Creative Arts Therapy Review,  11, 22-29. Martin, J. (1989). The role of body image in the development of bulimia. British Journal of Occupational Therapy, 52(7), 262-265. Miller, K. (1991). Body-image Therapy. Nursing Clinics of North America,  26(3), 727-736. Mindell, A. (1985). River's Way: The Process Science of the Dreambody, London: Routledge & Kegan Paul. Mitchell, J. E. (1992). Subtyping of bulimia nervosa. Special Section: Eating disorders in DSM-IV. International Journal of Eating Disorders,  11(4), 327-332. Mitchell, J., & Eckert, E. (1987). Scope and Significance of Eating Disorders. Journal of Consulting and Clinical Psychology,  55(5), 628-634. Naitove, C. (1986). "Life's but a walking shadow": Treating anorexia nervosa and bulimia. Arts in Psychotherapy, 13(2), 107-119. Neufeld, K. K. (1983). Phenomenological case studies of bulimia. Dissertation Abstracts International, 44, 2045A. Palmer T. A. (1990). Anorexia nervosa, bulimia nervosa: Casual theories and treatment. Nurse Practitioner 15(4), 12-18. Patton, C. J. (1992). Fear of abandonment and binge eating: A subliminal psychodynamic activation investigation. The Journal of Nervous and Mental Disorders,  180(8), 484-490. Powers, P., & Schulman, R. (1987). Perceptual and cognitive abnormalities in bulimia. American Journal of Psychiatry, 144(11), 1456-1460. Printz, D. (1989). Self-expectations and bulimia. Dissertation Abstracts International,  50, 5330B. 173 Progoff, I. (1963). The Symbol and the real. New York: McGraw-Hill Book Company. Rand, C. S., & Kuldau, J. M. (1992). Epidemiology of bulimia and symptoms in a general population: Sex, age, race, and socioeconomic status. International Journal of Eating Disorders, 11(1), 37-44. Reynolds, B. S. (1991). The role of shame in anorexia nervosa and bulimia nervosa. Dissertation Abstracts International, 52, 2783B. Richardson, G. (1982). Educational imagery. Springfield, IL: McGraw-Hill Book Company. Rojcewicz, S. (1990). Body image changes during guided affective imagery. Humanistic Psychologist, 18(3), 270-278. Root, M. P. P., Fallon, P., & Friedrich, W. N. (1986). Bulimia: A systems approach to treatment. New York: Norton. Rowen, H. R. (1991). The experience of being out of control with food: A phenomenological study. Dissertation Abstracts International,  52, 4984B. Rubenstein, C. S., Pigott, T. A., L'Heureux, F., Hill, J. L., & Murphy, D. L. (1992). A preliminary investigation of the lifetime prevalence of anorexia and bulimia nervosa in patients with obsessive compulsive disorder. Journal of Clinical Psychiatry, 53(9), 309- 314. Sanders, S. (1986). The Perceptual Alternation Scale: A scale measuring dissociation. American Journal of Clinical Hypnosis, 29(2), 95-102. Sankowsky, M. (1982). The effect of a treatment based on the use of guided visuo- kinesthetic imagery on the alternation of negative body-cathexis in women. Dissertation Abstracts International, 42(9-B), 3833. Schneider, J., & Agras, S. (1985). A cognitive behavioral group treatment of bulimia. British Journal of Psychiatry, 146, 66-69. Schindler, P. (1935). The Image and appearance of the human body. London: Kegan Paul. Schlesier-Carter, B., Hamilton, S., O'Neil, P., Lydiard, R., & Malcolm, R. (1989). Depression and bulimia: The link between depression and bulimic cognitions. Journal of Abnormal Psychology, 98(3), 322-325. Schulman, R., & Kinder, B. (1986). The development of a scale to measure cognitive distortions in bulimia. Journal of Personality Assessment,  50(4), 630-639. Sheehan, P. (1972). The function and nature of imagery.  New York: Academic Press. Shisslak, C., & Pazda, S. (1990). Body weight and bulimia as discriminators of psychological characteristics among anorexic, bulimic and obese women. Journal of Abnormal Psychology, 99(4), 380-384. Singer, J. (1979). Imagery and daydream methods in psychotherapy and behavior modification. New York: Academic Press. Spitzer, R. L., & Devlin, M. J. (1992). Binge eating disorder: A multisite field trial of the diagnostic criteria. International Journal of Eating Disorders, 11(3), 191-203. 174 Stewart, J., Walsh, B., Wright, L., Roose, S., & Glassman, A. (1984). An open trial of MAO inhibitors in bulimia. Journal of Clinical Psychiatry, 45, 217-219. Strasser, T. J., Pike, K. M., & Walsh, B. T. (1992). The impact of prior substance abuse of treatment outcome for bulimia nervosa. Addictive Behaviors, 17, 387-395. Swift, W., & Kahn, N. (1985). Depression in bulimia at 2 to 5-year follow-up. Psychiatry Research, 16(2), 111-122. Swirsky, D. (1991). The relationship between sexual abuse, dissociation and bulimia. Dissertation Abstracts International, 52, 2477A. Thackwray, D. (1991). Unsolicited reports of sexual abuse in a comparative study of treatment for bulimia. American Journal of Psychiatry, 148(12), 1754. Tennessen, J. E. (1991). Familial achievement patterns and their relationship to the development and maintenance of bulimia. Dissertation Abstracts International, 52, 4988B. Totten, D. P. (1990). The role of blood glucose in binge eating behavior. Dissertation Abstracts International, 51, 1514A. Tryniecki, T. M. (1991). Multidimensional self-concept in bulimic and non-bulimic women. Dissertation Abstracts International,  52, 3917B. Van Manen, M. (1990). Researching lived experience. London, Ont: The Althouse Press. Waller, G. (1992). Sexual abuse and the severity of bulimic symptoms.  British Journal of Psychiatry, 161, 90-93. Williamson, D. (1990). Assessment of eating disorders: Obesity, anorexia and bulimia nervosa. New York: Pergamon Press. Wiseman, C. V., & Gray, J. J. (1992). Cultural expectations of thinness in women: An update. International Journal of Eating Disorders,  11(1), 85-89. Wolf, N. (1990). The beauty myth. Toronto: Random House. Woodman, M. (1982).  Addiction to Perfection: The Still Unravishal Bride.  Toronto: Inner City Books. Wooley, S. C., & Kearney-Cooke, A. (1986). Intensive treatment of bulimia and body- image disturbance. In K. D. Brownell, & J. P. Foreyt (Eds.),  Handbook of eating disorders: Physiology, psychology, and treatment of obesity, anorexia, and bulimia  (pp. 476-502)._New York: Basic Books. Worth, C. A. (1989). Voices of women with eating disorders. Dissertation Abstracts International, 50, 2172B. Yin, R. K. (1989). Case study research: Design and methods. London: Sage Publications. Zaslove, L. (1991). The effect of sexual molestation on body image in women with bulimia. Dissertation Abstracts International, 52, 4992B. Zerbe, K. J. (1992). Why eating-disordered patients resist sex therapy: A response to Simpson and Ramberg. Journal of Sex and Marital Therapy,  18(1), 55-64. 175 Zulkosky, P. (1984). The wise woman in guided imagery: A feminist interpretation. Dissertation Abstracts International, 44(8-A), 2363. 176 APPENDIX A SUBJECT SOLICITATION FORM DEPARTMENT OF COUNSELING PSYCHOLOGY UNIVERSITY OF BRITISH COLUMBIA I am currently conducting research for my Master's Degree in Counseling Psychology on the use of Art Therapy and Guided Imagery in working with people who are bulimic. The goal of the project is to provide participants with meaningful, new insights into their body image and eating behavior. The project involves 1 one-hour case history interview; 12, one-hour sessions, and 1 one-hour follow-up session all of which will take place at UBC. All sessions will be conducted under the supervision of a UBC Counseling Psychology faculty member and will be kept strictly confidential. During the sessions, you will be asked to discuss your history of coping with your feelings about eating and your self- image. You will also be asked to create several drawings and to take part in some guided imagery exercises which involve simple relaxation and visualization techniques. No drawing skill is required. If you are interested in participating please answer the questions below and read and sign the attached consent form. PLEASE PLACE APPROPRIATE NUMBER IN THE SPACE PROVIDED: +^+^+^+^+ 1 2 3 4 5 Totally Neutral Totally Disagree Agree I. DURING THE PAST 3 MONTHS I HAVE BINGED AT LEAST TWICE A WEEK. II. I FREQUENTLY ENGAGE IN THE USE OF SELF-INDUCED VOMITING IN ORDER TO PREVENT WEIGHT GAIN. III. I FREQUENTLY ENGAGE IN THE USE OF LAXATIVES OR DIURETICS IN ORDER TO PREVENT WEIGHT GAIN. IV. I FREQUENTLY ENGAGE IN THE USE OF VIGOROUS EXERCISE IN ORDER TO PREVENT WEIGHT GAIN. V. I FREQUENTLY ENGAGE IN THE USE OF STRICT DIETING OR FASTING IN ORDER TO PREVENT WEIGHT GAIN. VI. I FREQUENTLY FEEL THAT MY EATING IS OUT OF CONTROL. VII. I AM ALWAYS VERY CONCERNED ABOUT MY BODY SHAPE AND WEIGHT. 177 APPENDIX B UBC LETTERHEAD SUBJECT CONSENT FORM DEPARTMENT OF COUNSELING PSYCHOLOGY UNIVERSITY OF BRITISH COLUMBIA Date: ^ agree to participate in a research project entitled, "Treating bulimics: The use of imagery to heal" which is being conducted by Michelle Gibson for her Master's Thesis under the supervision of Dr. Larry Cochran (822-5259). The study involves a one-hour interview and twelve, one-hour therapy sessions (2 sessions per week) during the period of November 2 - December 18, 1992. There will also be a one-hour, follow-up visit in January, 1993. The procedures to be followed and the purposes of the study have been explained to me. As I understand it, the study requires me to discuss issues surrounding, and including, my eating habits and my body image. I also understand that during the course of the sessions I may be required to create several drawings and participate in guided imagery exercises consisting of relaxation and visualization techniques. I also understand that my sessions may be tape-recorded and I will be asked to complete a number of questionnaires. I understand that any questions that I may have during the course of the project will be addressed and that I will receive feedback regarding my participation. I understand that there are no foreseeable risks to my health or safety. I understand that I may refuse to participate and that I am free to withdraw at any time. All information is strictly confidential. While findings may be used in future studies or publications there will be no identification of me personally on any records. I understand that I will receive no compensation (monetary or otherwise) and that my current participation does not obligate me to participate in future. I have read and understood the content of this consent form, a copy of which I have received, and agree to participate in this study. Signature: 178 4i'vo,of Figure C1.2. The coffin. 180 Figure C1.3. Living room. 181 Figure C1.4. How the world sees me. 182  Figure C1.6. My Inner Healer , 184 '71 0 c.) Figure C2.2. The Path. ,-"` Figure C3.1. The Grey Filter Mask. 187 Figure C3.2. Closeup of the filter. 188 Figure C5.1. The feeling of being a prostitute Figure C5.2. No. Figure C8.1. Red heart.  Figure C8.3. Third drawing. Figure C10.1. The Warrior. .4 194 Figure C12.1. How the world sees me. I,: Figure C12.2. What I see when I look in the mirror. Figure C12.3. My inner healer. 197 Poppa. ti■••. • M = P-1 CD CII o•—■ iss) t..) o 0  Figure S1.5. What I see when I look in the mirror. \ 202 IV 0 L.) Figure S2.1. Male and female. 204  Figure S6.1. The heart. -266 Figure S9.1. Little black devil. 207 Figure S12.1. How the world sees me. Figure S12.2. What I see when I look in the mirror. 209 •AS, tsJ 0 Confusion. 211 Figure A1.2. Isolation.  Figure A1.4. How the world sees me. 214 Po •--4 co) 8 ^... ^It CD 1—• Oa ^I■1 ^,.9 5 (t)0 >. ^ 5*^!-/1 s --CD 4. 0 1.-1 tv I—, Cn 4 ..,^ot -•^..;,—;• z CD^"I-I CD > g.n^!::" :-1 tv I-, 0l N r-i ol gwi...., cNi^.< cNi 0 .‹ 0 cu ,41.^+4 =E={ 1 li)4 4 <4 cu g Figure A2.2. Black Self. 218 Figure A2.3. Feelings for parents. 219 Figure A3.1. The yelling man. 220 Figure A3.2. The protector Aura. 221 Figure A4.1. Male and female. 222 Figure A4.2. Twelve year old. 223 Figure A5.1. Terror and vertigo. Figure A5.2. My spirituality. 225 Figure A5.3. The nagging doubt. 226 Figure A6.1. What I lose by giving up binging. 227 Figure A7.1. Thick wall. , 228  0 CDco) 0 ro . 0 P 07. t • P CDr:.-8 t...) L,..) 0  Figure Al2.2. What I see when I look in the mirror. 233 nr ce) cl Figure A11.1. The seagull. 231


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