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Case studies of the bulimic experience Gibson, Michelle Louise 1993-10-23

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CASE STUDIES OF THE BULIMIC EXPERIENCEbyMICHELLE LOUISE GIBSONB.A., UNIVERSITY OF BRITISH COLUMBIA, 1979A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTER OF ARTSinTHE FACULTY OF GRADUATE STUDIESDEPARTMENT OF COUNSELLING PSYCHOLOGYWe accept this thesis as conformingto the required standardUNIVERSITY OF BRITISH COLUMBIAAPRIL, 1993© M. L. GIBSON, 1993In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.(Signature)Department of cotkiCLNE.) 1yc0,6(--)1The University of British ColumbiaVancouver, CanadaDate^11_4 /(cji3.,DE-6 (2/88)ABSTRACTAlthough 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 adetailed body of knowledge based on three case studies of the subjective experiences ofbulimic women. Three self-selected women from the self-help group, OvereatersAnonymous, volunteered for the study. Participation was contingent upon the completionof a DSM-IIIR symptom checklist identifying substantive amounts of bulimic behavior.Each woman participated in a one-hour case history pre-interview; twelve, one-hoursessions; and a one-hour follow-up interview six weeks after sessions terminated. Thetwelve sessions were intended to provide a safe environment in which to explore thebulimic experience aided by the use of art therapy and guided imagery exercises wheredeemed appropriate by both counsellor and client. Four findings in the study validatedexisting phenomenological research. They were: fear of losing control leading to feelingsof abandonment; the use of bulimia as a protective shield; a desire to purify; and globaland food-specific shame and guilt. Nine themes extended findings from previous research.They were: a sense of Godlessness, self-doubt, feeling like a 'freak', opposingattitudes/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 patternof experience of the bulimic woman's journey of healing. Participants reported positivebenefits from the use of guided imagery in that they felt it enabled them to accesspreviously inaccessible thoughts and feelings. These findings may be useful for boththeoretical and practical application.TABLE OF CONTENTSAUTHORIZATIONABSTRACTTABLE OF CONTENTSLIST OF FIGURES^ viiACKNOWLEDGEMENTS xivI. Introduction^ 1Statement of the Problem^ 1Research Question 1Rationale^ 2Definition of Major Terms^ 3II. Literature Review 5Prevalence^ 5Biological Factors 6Familial Factors^ 7Sexual Abuse Factors 8Sociocultural Factors^ 9Treatment Approaches 11Use of Imagery^ 13Phenomenological Studies^ 15Overall Summary of the Literature Review ^ 17III. Method^ 18Design 18Participants^ 20Cynthia Background^ 20Sonya Background 20Alison Background^ 21Counselling Program 21Sources of Information^ 23Audiotapes and Transcriptions 23Imagery^ 23Therapist's Log 24Reflective Discussion^ 24Opportunistic Sources of Evidence^ 24Telephone Debriefings^ 24Procedures^ 25Analysis 25IV. Case studies^ 29Cynthia^ 29Session 1^ 29Therapist's Log, Session 1^ 32Session 2 34Therapist's Log, Session 2 39ivTelephone Debriefing, Week 1^ 40Session 3Therapist's Log, Session 3Session 4Therapist's Log, Session 4Telephone Debriefing, Week 2Session 5Therapist's Log, Session 5Session 6Therapist's Log, Session 6Telephone Debriefing, Week 3Session 7Therapist's Log, Session 7Session 8Therapist's Log, Session 8Telephone Debriefing, Week 4Session 9Therapist's Log, Session 9Session 10Therapist's Log, Session 10Telephone Debriefing, Week 5Session 11Therapist's Log, Session 11Session 12Therapist's Log, Session 12Telephone Debriefing, Week 640424344454547485050505252565657585861616164646768VSonya^ 68Session 1Therapist's Log, Session 1Session 2Therapist's Log, Session 2Telephone Debriefing, Week 1Session 3Therapist's Log, Session 3Session 4Therapist's Log, Session 4Telephone Debriefing, Week 2Session 5Therapist's Log, Session 5Session 6Therapist's Log, Session 6Telephone Debriefing, Week 3Session 7Therapist's Log, Session 7Session 8Therapist's Log, Session 8Telephone Debriefing, Week 4Session 9Therapist's Log, Session 9Session 10Therapist's Log, Session 10Telephone Debriefing, Week 5Session 11Therapist's Log, Session 11687173757576787879808081828485858888898989909191929293viSession 12^ 93Therapist's Log, Session 12^ 94Telephone Debriefing, Week 6 95Alison^ 95Session 1^ 95Therapist's Log, Session 1^ 100Session 2 101Therapist's Log, Session 2 106Telephone Debriefing, Week 1^ 107Session 3^ 108Therapist's Log, Session 3 110Session 4 110Therapist's Log, Session 4^ 112Telephone Debriefing, Week 2 113Session 5^ 113Therapist's Log, Session 5^ 115Session 6 116Therapist's Log, Session 6 118Telephone Debriefing, Week 3^ 119Session 7^ 119Therapist's Log, Session 7 121Session 8 121Therapist's Log, Session 8^ 123Telephone Debriefing, Week 4 123Session 9^ 123Therapist's Log, Session 9^ 125Session 10 125Therapist's Log, Session 10 127Telephone Debriefing, Week 5^ 127VIISession 11^ 128Therapist's Log, Session 11^ 130Session 12 130Therapist's Log, Session 12 132Telephone Debriefing, Week 6^ 133Follow-up Results^ 133Cynthia^ 133Sonya 134Alison^ 135V. COMPARATIVE ANALYSES OF THE CASES^ 136Aspects of ways of construing and experiencing 136Fear of losing control leading to feelings of abandonment^136The use of bulimia as a protective shield^ 137A desire to purify^ 139Global and food-specific shame and guilt^ 139A sense of Godlessness^ 140Self-doubt^ 143Feeling like a 'freak'^ 143Opposing attitudes/desires on a singe issue^ 144Self-pity^ 144Disenchantment with the perceived female role^ 146Exceptional concern for the perceived down-trodden 147The memory of an unsafe childhood^ 148viiiFear of Intimacy^ 149Patterns of Experience 150Destructive Phase^ 150Channelling Behavior^ 151Restorative Drama Phase 151Transitional Drama Phase^ 153Results of Transformation 154Summary of Transformation^ 155VI. DISCUSSION^ 156Statement of Findings 156Limitations^ 156Implications for Theory^ 158Major Findings 158A Common Orientation^ 160Minor Findings 162Implications for Practice^ 164Implications for Future Research 165Summary^ 169VII. REFERENCES^ 170APPENDICES 177ixList of FiguresCYNTHIAFigure C1.1. Kite.^ 179Figure C1.2. The coffin. 180Figure C1.3. Living room.^ 181Figure C1.4. How the world sees me.^ 182Figure C1.5. What I see when I look in the mirror.^ 183Figure C1.6. My Inner Healer^ 184Figure C2.1. The Separation. 185Figure C2.2. The Path.^ 186Figure C3.1. The grey filter mask.^ 187Figure C3.2. Closeup of the filter. 188Figure C5.1. The feeling of being a prostitute^ 189Figure C5.2. No.^ 190Figure C8.1. Red heart. 191Figure C8.2. Flower behind bars.^ 192Figure C8.3. Third drawing. 193Figure C10.1. The Warrior.^ 194Figure C12.1. How the world sees me.^ 195Figure C12.2. What I see when I look in the mirror.^ 196Figure C12.3. My inner healer.^ 197xList of FiguresSONYAFigure S1.1. Poppa.^ 198Figure S1.2. My kids. 199Figure S1.3. Vacationland.^ 200Figure S1.4. How the world sees me.^ 201Figure S1.5. What I see when I look in the mirror.^ 202Figure S1.6. My inner healer.^ 203Figure S2.1. Male and female. 204Figure S4.1. Yellow.^ 205Figure S6.1. The heart. 206Figure S9.1. Little black devil.^ 207Figure S12.1. How the world sees me. 208Figure S12.2. What I see when I look in the mirror.^ 209Figure S12.3. My inner healer.^ 210xiList of FiguresALISONFigure A1.1. Confusion.^ 211Figure A1.2. Isolation. 212Figure A1.3. Bird.^ 213Figure A1.4. How the world sees me.^ 214Figure A1.5. What I see when I look in the mirror.^ 215Figure A1.6. My inner healer.^ 216Figure A2.2. The AA and the OA Alison.^ 217Figure A2.2. Black Self.^ 218Figure A2.3. Feelings for parents.^ 219Figure A3.1. The yelling man. 220Figure A3.2. The protector Aura.^ 221Figure A4.1. Male and female. 222Figure A4.2. Twelve year old.^ 223Figure A5.1. Terror and vertigo. 224Figure A5.2. My spirituality.^ 225Figure A5.3. The nagging doubt. 226Figure A6.1. What I lose by giving up binging.^ 227Figure A7.1. Thick wall.^ 228Figure A9.1. The screen. 229Figure A10.1. Desirable characteristic.^ 230Figure A11.1. The seagull.^ 231xiiFigure Al2.1. How the world sees me.^ 232Figure Al2.2. What I see when I look in the mirror.^ 233Figure Al2.3. My inner healer.^ 2343diiACKNOWLEDGEMENTSDr. 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 basedin a variety of therapeutic paradigms. Two therapists were truly instrumental in myrecovery. One utilized guided imagery. The other encouraged me to draw. I have marriedthese approaches and changed them considerably for this study, but I owe the genesis ofthis thesis to Eva Di Casmirro in Vancouver and Patti Parry in Toronto.xivI. IntroductionStatement of the ProblemReports of bulimia were once so rare that it was considered a medical curiosity. Infact, it was not officially classified as a separate psychiatric disorder until the publication ofthe DSM-III in 1980. However, over the past 15 years, the reported incidence andprevalence of bulimia in the western world has increased (Bendfeldt-Zachrisson, 1992).During the period of 1979-1987, the Stanford Eating Disorder Clinic's reported annualnumber of cases of bulimia rose from 10 to over 200 (Agras, 1987). By 1990, Palmerreported that a "near-epidemic proportion" (p. 12) of 1.2 million adolescent/young adultfemales in the U.S. had an eating disorder. Some researchers, such as Wolf (1991), havegone so far as to suggest that the norm for young, middle-class American women, "is to be asufferer from some form of eating disease" (p. 182).Bulimia has important relations to a number of other prevalent physical andpsychological issues including: depression (Hartmann, Herzog & Drinkmann, 1992), sexualabuse (Thackwray, 1991), substance abuse (Bulik, 1992), and personality disorders(Rubenstein, Pigott, L'Heureux, Hill & Murphy, 1992). Its connection to otherphenomenon, increasing reports of bulimia, and a general lack of information or consensusregarding many facets of the disorder, support the need for more study (Williamson, 1990).Research QuestionBulimia is an increasing problem in western civilization and yet much about thedisorder remains a mystery. Facilitated through the use of imagery., this thesis aimed toshed additional light on the enigma of bulimia through intimately exploring how threebulimic women interpreted their world: their motives, life-historical content, andperceptions. Specifically, this thesis attempted to answer the question: What is themeaning of the female experience of bulimia?1RationaleRowen (1991) suggests that insufficient approaches and methodologies, andcontroversy among researchers, has undermined investigators' abilities to study the essenceof binge eating. Nosological problems in the literature have outlined the need to betterunderstand the underpinnings of the multi-faceted life experience of the bulimic. Ford(1985) found major differences among bulimics who were fasters, vomiters or laxativesabusers. The laxative abusers, for example, showed significantly more overall distress thanthe vomiters and fasters. To that end, possible subtyping options for the diagnosis ofbulimia 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 bulimicwomen's subjective experiences within the framework of a treatment program. Atreatment program was employed, rather than a series of in-depth interviews, to provide asmuch opportunity as possible for each of the women to experience change. Change isviewed by many (Arkowitz, 1989; Bronfenbrenner, 1979; Guidano and Liotti, 1983) as aneffective method by which much new information can be acquired and processed. Changewas encouraged throughout treatment using an eclectic variety of paradigms in response toeach of the individual women's ways of being. These various responses grew out of a coreapproach which was a client-centered foundation of unconditional positive regard. Fromthat foundation, Egan-model (1990) problem-managing and opportunity-developingstrategies, gestalt role-playing, rational-emotive therapy, and cognitive-behavioralrelaxation techniques were all employed accordingly in an effort to respond to the uniquenature of each woman.In considering accessing the bulimic woman's thoughts, much of the informationcollected has concentrated on the explicit mind. Researchers and/or therapists haveappealed to a mode of thinking which analyzes, verbalizes, abstracts and makes rationalstatements based on rational thought (Miller, 1991). Perhaps, the limited success in2understanding 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 ofimagination is mainly tacit and indirectly noticed by the individual, who would havedifficulty 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, theimaginal stream can be considered as one of the more characteristic ways in which anindividual's tacit self-knowledge is manifested" (p. 77).During the course of treatment the imaginal stream was tapped through the use ofboth external (art therapy) and internal (guided imagery) imagery. It was hoped that theaddition of imagery work would prove to be a valuable component and catalyst ingenerating insights from the tacit realm into the essence of the bulimic experience. Thechoice of these two techniques for this study was based on the hypothesis that guidedimagery accesses the tacit self (Achterberg, 1985). And drawing may function as a bridge(Allan, 1978) by making introspective images visible on paper potentiating explicit analysisand verbalization of implicit material.Definition of Major TermsThis section reviews definitions for the following constructs of interest pertaining tothis thesis. The definitions include: bulimia, body image, art therapy, the Three SelvesTest, 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 foodin a discrete period of time). It is accompanied by a feeling of lack of control over eatingbehavior 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 toprevent weight gain. Other diagnostic criteria include a minimum average of two binge3eating episodes a week for at least three months, and a persistent over-concern with bodyshape and weight.The term body image has diverse connotations. For this study it has been defined asa) the way in which our body appears to ourselves (Lacey & Birtchnell, 1986), b) the way inwhich we take in attitudes and feelings toward the body that occur as individuals view andexperience their body in interaction with others across time (Kolb, 1975), and c) a methodof perception that has a conscious and unconscious component, the formation of whichinvolves crucial interaction among social, psychological and physiological factors(Schindler, 1935).Art therapy is ostensibly the employment of creative processes in an effort to accessand to nurture psychological healing. Defined for this study, it is a colour drawingtechnique relied upon at relevant points during the therapy session, i.e., draw a picture ofyour family at the dinner table, as a tool to develop introspective images by making themtangible on paper.The Three Selves Test (TST) (Gibson, 1992) is a treatment and measurement tooldesigned and operationalized for this study. The TST consisted of clients being asked todraw, 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 relevantconscious information, creativity, and tacit symbols. Ideally, the combination allows imagesto come forth within the mind of the client which they may chose to share with the therapistfor the purposes of exploration and discussion.4II. Literature ReviewThis section reviews research as it pertains to the prevalence, possible contributingfactors, treatment approaches, body image, art therapy, guided imagery and documentedphenomenological experiences of bulimia.PrevalenceIn spite of increases in reported incidents of bulimia over the past two decades,epidemiological surveys attempting to chart these developments are rare. Reports ofincidence/prevalence in populations other than high school or college students areextremely limited (Hart & 011endick, 1985). One general population survey has beenconducted. Rand and Kuldau (1992) surveyed 2,115 adults and found prevalences ofbulimia 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 onhow 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 thesymptoms described by bulimics are also common in the general population. There stillexists a lack of consensus regarding which level of eating pathology is the critical point orthreshold separating normal eating behaviors from eating disorders. To that end, Fairburnand Beglin (1990) recommend rather than studying the distribution of the disorder, a moreimportant focus is one that concentrates on an examination of the determinants of theentire spectrum of the disorder. An emerging consensus among investigators of bulimia isthat it is a multideterminet1 disorder the development and maintenance of which is effectedby biological, familial, sexual abuse, and sociocultural factors (Grissett, 1991).5Biological factorsProponents of the biological paradigm suggest that there is a direct correlationbetween the development and maintenance of bulimia and pathophysiology. Explanatoryproposals include a lack of glucose homeostasis (Totten, 1990), regulatory dysfunction ofthe hypothalamus, a possible common etiology between bulimia and affective disorders,and bulimia as a variant or type of seizure disorder (Bendfeldt-Zachrisson, 1992). So farresearch in these areas, although interesting, is not sufficient to be able to point to apossible 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 ofbulimics suffered from affective disorder. Swift and Kahn (1885) found that the higher thedepression scores, the more intense the bulimic symptomatology and attitudes. Thisfinding was corroborated by Schlesier-Carter, Hamilton, O'Neil, Lydiard and Malcolm(1989) who provided evidence that bulimics were significantly more depressed thancontrols and that they showed more maladaptive thinking associated with depression.In spite of substantial research into the connection between depression and bulimiathe relationship between depression and bulimia remains poorly understood (Fornari,Kaplan, Sandberg, Matthews, Skolnick, & Katz, 1992). Furthermore, a fair amount ofcontroversy still exists regarding whether depression is a consequence of the eating disorderitself or whether bulimia is subordinated to depression (Bendfeldt-Zachrisson, 1992).A further contributing confound in the debate over the connection betweendepression and bulimia exists in that greater externality has been associated with greaterdepression (Benassi & Sweeney, 1988). A recent meta-analytic review (Hartmann et. al.,1992) found that depression and locus of control were consistently and moderately relatedacross studies. There appears to be a correlation between external locus of control and the6occurrence of bulimia in women (Shisslak & Pazda, 1990; Leclair, 1984). Bulimic womenexhibit 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, likelow self-esteem, found among the most underweight bulimics.Familial FactorsAnother possible determinant which has been considered as a fundamental and/orexacerbating factor in the development and maintenance of bulimia is familialrelationships. Families of eating disordered patients tend to have difficulty withboundaries, conflict management, and support for autonomy (Connors & Morse, 1993).Hathaway-Clark (1991) hypothesized that because bulimics tend to be high achievers whostruggle with sex role and relationship issues, their fathers may emphasize achievement butbe unavailable for a loving relationship. She was, however, unable to demonstrate thatfather-daughter relationship issues contributed uniquely to symptomatology associated withbulimia. According to Belt (1990), a parental care style of low empathy and high controlmay be negatively correlated with eating disorder symptomatology. In religious families ofbulimics, God was portrayed as a controller, a protector, and a judge; a perception whichLavaIlee (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 tohold unrealistic expectations regarding their daughters' attractiveness. Grace (1990)suggested that increased bulimic symptoms may result if an affectively unstable daughter israised by a non-bulimic, narcissistic mother. Grace felt that the daughter's bulimic strugglemay represent an effort to achieve independence and a separate identity from her mother.Compared to non-eating disordered women, bulimics perceive significantly lesssocial support from both friends and family along with more negative interactions andconflict, particularly with family members (Grissett, 1991). Global difficulties withinterpersonal relationships have been linked with problems in the symbiotic and7separation-individuation phase of development. Kramer (1991) suggests that suchdisturbances play a causal role in the development of bulimia. It may be that the bulimicperceives separation as a form of rejection of her family reflecting problems in "passage outof adolescence and into independent adulthood" (Wooley & Kearney-Cooke, 1986, p. 478).Finally, the presence of siblings may affect the development and maintenance ofbulimic behavior. Lewis (1988) found sibling relationships to be an important factor in thatbulimia may be used as an indirect expression of affect to a sibling. It may also be used asa means of getting out of a complementary role with a sibling, or as an expression ofimmobilizing ambivalence in the sibling relationship.Sexual Abuse FactorsAnother contributing factor in the development and/or maintenance of bulimia maybe a history of sexual abuse. Up to 65% of eating disordered patients describe severesexual or physical trauma as children (Zerbe, 1992). Swirsky (1991) studied therelationship between childhood sexual abuse experiences, dissociation, personality styles,and bulimic experiences in women and found that, although abused bulimics weresignificantly more dissociative than were non-abused bulimics, there was no relationshipbetween the severity of the bulimia and dissociation. On the other hand, Waller (1992) didfind that a bulimic woman with a history of sexual abuse tended to binge, and to a lesserextent, purge, more frequently. Further, he observed that the symptoms of bulimia wereexacerbated when the abuse was intrafamilial, involved force, or occurred before the victimwas 14 years old.Abused bulimic women demonstrate a higher level of body dissatisfaction, apronounced experience of feeling fat, and more overall psychological distress thannonabusecl bulimics (Zaslove, 1991). Zerbe (1992) notes that some eating disorderedpatients may respond to their childhood sexual trauma with sexual promiscuity inadulthood. She suggests that promiscuity serves as a method by which to search for an8omnipotent caretaker, to allow the self to be more cohesive, and to avoid fragmentation bymerger 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 somepatients there may be a direct connection between sexual trauma and eating pathology, ingeneral, sexual abuse is best regarded as a risk factor.Sociocultural FactorsAnother possible determinant of bulimia is the value society places on possessing athin body type. Thinness is an increasingly socially desirable choice, (Wiseman & Gray,1992). Wiseman and Gray found that weight lose and exercise articles in women'smagazines had increased significantly over a 30 year period meanwhile the bodymeasurements of Playboy magazine centerfolds and Miss America Pageant contestants' for1979-1988 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 socialstandards that has exacerbated the prevalence of bulimia. Bulimics reason they canbecome more attractive through losing weight by purging/vomiting (Martin, 1989).If Agras (1987) is correct, it would appear that North America has embraced acertain set of social standards which may be contributing to bulimic behavior withastounding effectiveness. According to Wolf (1990), the growing numbers of eatingdisordered 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 dubiousworldwide front-runner of eating disorders.Why has North America become such a breeding ground for this disorder? Thereare several theories. Boskind-Lodahl (1976) initially suggested that women had fallenvictim to the media's propagation of very thin cultural models of beauty but she has sincerescinded that idea. In more recent years, she has found more differences than similarities9among patients and suggests more study is required. Wolf (1990) maintains that "a culturalfixation on female thinness is not an obsession about female beauty but an obsession aboutfemale obedience" (p. 187). She suggests that caloric restriction is a means by which todeflate a feminist revolution toward egalitarianism with men.A female desire to be thin may also be reflecting a revolution toward emulatingmen. As Wooley and Kearney-Cooke (1986) have observed, "this is the first generation ofwomen expected to live a life different from their mother's - a life, instead, like theirfather's. This change in women's role is probably not independent of the change inpreferred body type for women" (p. 478).In fact, the seemingly pandemic rejection of a classically feminine, round, soft, bodytype 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 capitalisticsocieties as a means of social distinction. He shores up this suggestion by pointing out thatin developing countries, where social class division is dramatic, eating disorders are foundeven 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 theopportunity for the recognition and growth of a different kind of survival challenge: that ofa sort of psychic famine. Woodman (1982) suggests that eating disordered women arebattling for a spiritual consciousness through food, using food as a method by which toaccess emotions. Woodman argues, "it may well be that the numinosity of food and drinkreflects the central crisis in our 20th-century culture: the crisis in faith. We live in apredominantly Christian culture which has lost its living connection to the symbolism ofwafer and wine. Lacking spiritual sustenance there is genuine hunger and thirst" (p. 28.)10Treatment ApproachesTreatment 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 attemptingto interrupt the bulimic cycle of eating by reinstating normal eating habits whilesimultaneously challenging accompanying distorted beliefs. Techniques such as contractualagreements or exposure to binge foods under therapist supervision combined withprevention of vomiting have typically been utilized. Some success has been reported withthe cognitive-behavioral approach. For example, Wilson and Eldredge (1991) reportedsignificant reductions in binging and purging in 22 patients over 20 sessions of cognitive-behavior therapy (CBT). Although the CBT approach does not render completerecoveries, 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 treatingbulimics. The pharmacological approach has been based on the hypothesis that bulimia isa form of an affective disorder. Drugs have been employed to reduce depression andanxiety 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 witheither imipramine or monoamine oxidase inhibitors reduced their binge eating. However,withdrawal of medication almost always resulted in relapse. In some cases, relapseoccurred despite continuation of the medication.Until recently, one possible impediment to recovery, regardless of the treatment ofchoice, was considered to be a bulimic with a history of substance abuse. Depending ondiagnostic criteria and sampling procedures, substance abuse among the bulimic populationhas been estimated at as high as 50% as compared to 5% among women in the generalpopulation (Strasser, Pike, & Walsh, 1992). However, Strasser et. al. (1992) found that a11past history of substance abuse has no implication regarding response to psychotherapeuticor pharmacological treatments for bulimia.No one treatment has yet been devised to enable a person who is experiencingbulimia to successfully recover. Most clinicians do not believe that there is a consensusregarding how to treat eating disordered patients (Herzog et. al, 1992). This impasse ispartially a result of the unique complexity of the disorder. Bulimia has strong psychologicaland physiological components that combine to confound any one therapy. One of the mostsuccessful treatment programs to date (Lacey, 1983) attempted to address bothcomponents. 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 andvery little relapse occurred during the 2-year follow-up. The results suggest that theaddition of the insight-directed therapy contributed to both greater understanding and to amore 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 differencesbetween 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 techniqueswere described in practically all studies" (p. 162) and that within those studies, "the extentand 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 tosignificantly improve the effect of the therapy" (p. 165).12Use of ImageryThis study aimed to afford an opportunity for more careful and extensivedescriptions through the use of both art therapy and guided imagery. Art therapy has beenapplied to myriad psychological problems (i.e., post traumatic stress disorder, Berkowitz,1990; masochism, Campbell, 1990; multiple personalities, Frye, 1990). Little work has beendone 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 foreating 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 treatmentof bulimia. Conn used art therapy to effectively access feelings and underlying issues withtwo hospitalized bulimic women. Naitove found that treatment was initially successful butwas prematurely ended. Wooley and Kearney-Cooke developed the Colour-a-Person testwherein patients were asked to colour in the outline drawing of a female body as a form ofself-assessment that began the process of body-image therapy. However the test wasemployed 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, mentalpictures 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 tofacilitate the generation of those images and mental pictures which have the inherentcapacity to arouse or uncover intense affective reaction and to enable deep emotionalexploration (Horowitz, 1970; Sheehan, 1972; Singer, 1979). The process affords access tosimilar 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 byFeinberg-Moss and Oatley (1990) who discovered no significant differences between13imagery and non-imagery treatment groups. However, imagery therapy was found to besignificantly better than an attention-only control group. They also conducted a follow-upsession, and asked clients to complete questionnaires on Likert-type scales regarding bothsatisfaction with treatment and therapist characteristics. Clients in the imagery groupprovided higher ratings on both dimensions.Several studies skirt the concept of treating bulimics with guided imagery throughaddressing 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 toexperience emotions. After five months of therapy, the client was able to summon thesensation of his whole body expanding. Zulkosky (1991) reported a rich set ofcommonalties among five women in her exploration of the 'wise woman' as a therapeutictool in guided imagery as a process of personal change. The effect of a treatment based onthe use of guided visuo-kinesthetic imagery on the alternation of negative body-cathexis inwomen has been examined (Sankowsky, 1982) resulting in measurable improvements inboth body and self-cathexis. An audio-taped imagery program has been employed as aprimary stimulus to investigate the perceived control and coping self-efficacy of femalebulimics (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 importantlife issues and events. Finally, Miller (1991) focussed on people with body-imagedisturbances. She suggested the use of imagery, along with the suggestion of mirror workand 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 guidedimagery. Hill (1992) documented the successful use of fairy tales as a safe vehicle by whichto bypass defense mechanisms and access underlying issues. Clients were encouraged toidentify with fairy tale figures and create action metaphors by working on resolutions forthe characters' problems which they could then adopt in dealing with their own issues.14Outcomes included the enabling of clients to experience "self-love not yet owned" (p. 586),that is, discovering that their beings are worth defending.Phenomenological StudiesSeveral studies have explored the bulimic world from a phenomenologicalperspective. 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 thebinge/purge cycle defensively. She also found bulimics to have difficulty with interpersonalrelationships, excessive self-criticism, and coping under stress.Tennessen (1991) discovered bulimic women were less satisfied with theirachievements and held less realistic expectations. Grissett (1991) reported that bulimicsfeel less socially competent in a variety of situations and were rated as less socially effectiveby observers unaware of their group membership. The global self-concept of bulimicwomen appears to be significantly lower and negative emotional response and deprecatoryself-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 ofsocial support received (Kramer, 1991). Worth (1989) found the issue of separation andthe creation of an autonomous sense of self to be a pivotal concern. Printz (1989) suggeststhat bulimics perceive that they are not living up to the expectations of their parents. Shealso found that bulimic women did not identify with the traditional feminine role.Jones (1989) discovered six themes in the bulimic experience. The first, the socialprocess 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 wereideal or perfect child, feelings of rejection, feelings of anger, deviant sick role, and the needfor secrecy. Herrington (1991) suggests the issue of control is common to all bulimics and15that 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 andoverwhelming world to the isolation of food. She describes bulimics as simply overpoweredby their desire, often experienced as an alien force, to surrender to a binge. The bingeusually brings temporary feelings of comfort and control as well as a reprieve from theirusual experience of self. If purging ensues after the binge, it functions to both preventweight gain and to regain a feeling of control. Herrington describes the bulimic's sense ofloss of control as extending beyond food to their sense of agency, and, often, even theirsense of self.Patton (1992) found fear of abandonment by significant others underlying disturbedeating behavior. She cites that 67% of bulimics recall a significant event involving the lossof, or separation from, an important relationship prior to the onset of their bulimia. Pattonsuggests that binge eating may be "one method bulimics use to alleviate fear ofabandonment and to symbolize merger with the maternal object when unconscious fearsare stimulated" (p. 484). Igoin-Apfelbaum (1985) discussed bulimic patients' symbioticfeelings for their mothers. He described them as both avoiding and being drawn to theirmothers while "the main feeling was that of shared inescapable distress" (p. 164).Women with eating disorders have been cited as experiencing more global shameand guilt as compared to normal women and they experience more shame and guilt inrelation 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 thedegree of internalized shame. His results supported several phenomenological experiencesreported by bulimics through the literature: the presence of feelings of inadequacy, beinghypercritical towards self, a wish to hide and avoid others, intense fears of abandonment, awish to be somebody else, and feelings of contamination and self-disgust. Reynolds alsoidentified several phenomena interpreted as defenses against shame includingperfectionism, envy, and struggles for power and control.16A number of phenomenological themes emerged from Neufeld's (1983) casestudies: abandonment by the father, need for protection and fear of failure, fear ofrejection, 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 anddepersonalization of self, need to purify, feeling like a sex object, fear of fear ofrelationships, feelings of worthlessness and, invalidation of perceptions.Finally, Hsu (1990) explored the cycle of the binge. He suggests that most bulimicwomen prefer to be alone when they binge and that negative feelings are common before abinge, especially those of depression, anxiety, and boredom. He also found that eatingvirtually anything is a "powerful precipitant of a binge for most bulimics" (p. 51). Hsucharted feelings throughout the binge/vomit cycle and discovered that dysphoric pre andearly binge feelings give way to feelings of "exhaustion and dirtiness" (p. 54) followed bygeneral 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 theentire episode. Hsu discovered that the most common self-statement made during theearly 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 Review1. Bulimia is a major health problem which is growing exponentially.2. No clear consensus has been reached regarding a critical point when eating behaviorbecomes 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 inorder to work toward answers for the above concerns.17III. MethodDesignThis study was implemented utilizing a multiple case study design. The multiplecase 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 beclaimed" (p. 38). Yin continues to expand on the usefulness of the case study approach ingeneral by suggesting that case studies afford an opportunity to explain connectionsbetween complex interventions which function beyond the realm of experiments.Woodman (1982) argued that bulimics are not consciously aware of their problemsor the depth of issues that are involved. For the purposes of this study, gaining access todeeper realms of the bulimic mind necessitated the use of more intuitive methods, such asart and fantasy. Many studies have employed questionnaires or interviews to explore thebulimic experience (Cooper & Fairburn, 1992; Hsu, 1990; Hsu & & Sobkiewicz, 1991;Keck, Pope, Hudson, McElroy, Yurgelun-Todd, & Hundert, 1990) limiting information towhat could be explicitly stated. This study sought to uncover implicit information utilizingnot only in-depth discussion but imagery as well.The use of imagery was intended to access tacit personal knowledge. The goal wasto 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 relativelyinaccessible inner landscapes. Guidano and Liotti (1983) suggest that the "relationshipwith self-knowledge can be only of an indirect type; that is, individuals use mainlyinferential procedures in order to construct those characteristics they consider to be theirdistinctive 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 imaginative18and emotional life, which are mainly regulated by tacit self-knowledge" (p. 60). In light ofGuidano and Liotti's observations, the benefit of attempting to fathom implicit personalknowledge, identifying fragments of thoughts and emotions, and bringing them to consciousawareness may be of particular relevance in the study of bulimia. Perhaps the lack ofprevious exploration of the tacit self in bulimic individuals may partially explain whybulimia is still so poorly understood.The exploration of the tacit self in this study was introduced within the framework ofa treatment program which attempted to promote change. Attempting to promote changewas viewed as an essential component of the study. In considering the accessing of the tacitself, Guidano and Liotti (1983) note, "the material sometimes represents an importantdemand for change in personal identity, since the imaginal stream tends to circumvent theindividual's attempts to maintain specific beliefs on self and reality through selectiveexclusion 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 processof "transforming experiments in the real world" (p. 40). Based on the above perceptions ofchange as a tool by which to gain further understanding, a treatment program, rather than aseries of interviews, was employed for this study.To determine the feasibility of a treatment program which would yield richinformation, two pilot studies were conducted employing both guided imagery and art. Thetwo, self-selected, bulimic clients, a 24 year old female and a 53 year old male, eachreceived four, one-hour-long sessions. The pilot study resulted in both clients reporting thediscovery of useful insights into their eating patterns, and very positive changes in boththeir bulimic behavior and their attitudes toward their body images. Both expressed astrong desire to continue treatment.19ParticipantsThree self-selected, bulimic women solicited from the self-help group, OvereatersAnonymous (OA), participated. The clients ranged in age from 23 to 35 years old. Clientsresponded to a personal request on the part of the student researcher at OA meetings. Allparticipants 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 fiveon each question) were accepted. Clients were also screened for their ability to articulatetheir experiences and for their availability.Cynthia background. Cynthia was a slim, 23 year old woman. She had a youngersister. Her parents were divorced. She was sexually abused by both her parents when shewas a child. During her teens, she was heavily involved in drugs, alcohol, and some streetactivity. 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 tothrow up. By the age of 15, she was binging and purging up to 20 times a day. When webegan our sessions, Cynthia was purging once or twice a day.Cynthia had seen several psychologists, psychiatrists, and counsellors over the yearsfor 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 andan older sister. Her father left the family when she was two weeks old. She was raised byher mom who was at times single, and at times married. Her mother's various husbandsfunctioned 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 notdrink, smoke, or take drugs. She was agoraphobic. She had been bulimic for 22 years,20since she was 13. Sonya had binged and purged over the years to the point of damaging heresophagus. For that reason, she had had to curtail her purging to "spitting" out food aftermasticating but before swallowing. She did this many times a day. Sonya had seen manypsychiatrists, psychologists, and counsellors over the years.Alison background. Alison was a slim, 33 year old woman. She had an olderbrother who lived in Alberta. Her parents were retired on Vancouver Island. At the timeof our work together, She was experiencing her first long-term, live-in, relationship with aman named, Jordy.Alison became an alcoholic at age 12. She quit drinking two years ago and hadstayed sober. She quit smoking three months ago. She had never really done drugs. Herparents never knew that she drank or smoked. Nor had Alison ever told them about hereating 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 shewas happy or sad. Usually, she would binge for about five days straight and then purge itall out. Alison had never seen a counsellor prior to our work together.Counselling ProgramAll treatment took place at the U.B.C. Counseling Psychology building. Thetheoretical framework within which the treatment program occurred was one of humanism.Specifically, client-centered therapy was employed as a caring and supportive method bywhich to conduct in-depth discussions and information-gathering within a primaryframework of unconditional positive regard. Secondarily, an eclectic assortment oftherapeutic paradigms were introduced throughout the course of treatment to encourageand support positive change. For example, Gestalt role-playing was employed in an effortto rehearse for difficult or frightening situations; rational-emotive therapy was utilized inan effort to amplify and explore irrational thought processes; and cognitive-behavioral21.relaxation techniques were used in order to provide an opportunity for participants toexperience some inner peace.Art therapy and guided imagery techniques were introduced as complementaryprocesses by which to further facilitate the expressive abilities of the client. The use ofdrawings 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 discussedbriefly. The whole exercise was designed to free clients from concerns about their lack ofskill and/or talent and/or aesthetics when creating artwork in front of a therapist. TheThree 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 evolvedout of discussion, i.e., a subject might mention a feeling of tension at the family dinnertable 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 asdictated 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. Thetherapist may then suggest conducting some guided imagery work around that block. Theguided 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 inher body from whence the tensions or feelings regarding a particular issue seemed to beemanating. The client then reported the images that she 'saw' and a conversation regardingthat phenomenological experience ensued. In an effort to respond to client needs, no setnumber of guided imagery exercises per session was required.Finally, openness to client experience on the part of the therapist was earnestlyattempted in order to achieve depth, richness, and insights into the client's world. To thatend, the therapist attempted to adopt what Arnold Mindell (1985) describes as the fluid22ego wherein one is open to "the body experience, mood, or fantasy" (p. 65). A client'sfleeting glances, brief pauses, shifting body movements, and the like, were responded to bythe therapist with the use of immediacy to facilitate deeper elaborations. In this spirit, thetherapist 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 withhis primary processes in time and space, and also with the stream of events, thosesecondary perceptions. He maintains his normal sober intellectual consciousness whilesimultaneously participating in processes" (p. 66).Sources of InformationData were collected through a participant-observation multiple case study formatemploying: 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 coredata collection strategy. Audiotapes of each session were transcribed immediatelyfollowing each session.Imagery. The use of imagery as a data collection strategy constituted an entirelydifferent language, requiring different "words" and forms of expression. The drawings andsymbols created through the use of art therapy and guided imagery exercises provided avery different perspective through which to process the bulimic experience. Ideally,encouraging the bulimic to speak in a relatively new and different "language" would sparkthe release of undiscovered information from their psyche which could then be translatedinto speech and conscious thought.The TST was used to contrast any changes which occurred in the nature of the threedrawings 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 ahouse, a tree, and a person and attempted to glean information about the client based on23the way those items were rendered. Clearly, the TST was a novel and largely unvalidatedmeasurement and treatment tool.Therapist's log. The therapist's journal served as a subjective participantinvestigator record of observations not apparent in the session transcriptions. Unspokenactions, the ambiance in the room during the sessions, and client energy levels were allrecorded in the therapist's log immediately following each session. The therapist's log waswritten based on recommendations by Van Manen (1990) to attempt to describe theexperience of the session "from the inside, as it were; almost like a state of mind: thefeelings, the mood, the emotions" (p. 64).Reflective discussions. The reflective discussions were conducted in person and onthe telephone between the thesis supervisor and the researcher on several occasionsthroughout the course of data collection. The discussions served as an objective landscapein which to document cycles of transformation and to reflect on the potential implicationsof session developments. Questions were posed about the treatment sessions, doubts wereexpressed, hypotheses were shaped and reshaped, and new approaches to roadblocks orweak links in gleaning the essence of the bulimic experience were formulated. For thereflective 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 aclassical physicist.. .holding his distance from events" (p. 66).Opportunistic sources of evidence. Opportunistic sources of evidence provided amethod by which additional material could be acknowledged and processed. This categoryprovided the opportunity for evidence such as photographs, dreams, and significant peoplein the lives of the participants to be incorporated into data collection.Telephone debriefings. Finally, the weekly telephone conversations afforded clientsthe opportunity for further reflection regarding the content, and ramifications of thoughtsand emotions explored in the sessions. It was hoped that both the physical and the24chronological distance from the sessions would provide the ability for a differentperspective to be experienced and expressed by the clients.ProceduresPrior 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 theirreflections on the week's work and any additional insights they may have had into theirbehavior.Approximately six weeks after the final sessions, clients were asked to offer theircomments, feelings, and reflections experienced in the aftermath of the study in an hour-long interview. This session provided an opportunity to defuse any possible negativeconsequences of, or field any positive comments about, having participated in the study.AnalysisMaterials gathered over the course of the sessions were processed systematicallyand exhaustively with two focuses in mind: identifying aspects of construing andexperiencing, and discovering patterns of experience. These two focuses became the"descriptive framework" (Yin, 1989, p. 107) by which to fathom and analyze case studiesmaterial for insights and content linkages.Overall synthesis and analysis of the data embraced Van Manen's (1990) approachwhereby many levels of assessing a phenomenon were incorporated. To begin, eachwoman's 12-session account of her bulimic experience was intimately reflected upon as awhole. Next the accounts were reappraised such that significant units of meaning relatingto each woman's bulimic experience were extracted; transient, irrelevant material wasculled 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 of25transformation. Preliminary clustering of themes emerged from dozens of phases pulledfrom the transcripts which had the potential for units of meaning. Most phases were culledout. The high repetition phases were then reflected upon as possible themes. Once thedifferent themes had been formulated, the original transcripts were revisited in an effort toguard against the possibility of distortion of the data. This process was followed by a liningup of units of meaning, or themes, across the individual case studies. Finally, thecommonalty of the meaning of the bulimic pattern of experience was sought across thewomen's cases.Each source of evidence provided a unique contribution to the descriptiveframework. Transcriptions of audiotaped sessions, opportunistic sources of evidence, andtelephone conversations were employed to create detailed accounts of the clients'subjective, explicit worlds. Session summaries presented in the case studies chapter are theresult of careful, thoughtful distillation of the most salient units of meaning which becameapparent in the sessions. Yin (1989) defines an "embedded unit of analysis (unit ofmeaning or theme) as.. .a lesser unit than the case itself, for which numerous data pointshave been collected" (p. 121). Depending upon whether or not conversations within eachsession were perceived to be pivotal links in the chain of themes being forged, entiresections or only quick synopses were related. For example, consider 'a sense ofGodlessness' as a unit of meaning. Whenever any of the participants chose to elaborate ontheir feelings shedding light on the nature of that specific theme, the completedocumentation 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, werefaithfully charted in an effort to build a rich and deep context of individual experience foreach bulimic woman.Following documentation of each woman's own experiences, the therapist's logswere incorporated into analysis as secondary sources of information. The therapist's26subjective experiences of the sessions functioned as a method by which to make implicitinformation, such as a client's general energy level during a session, more explicit.The greatest opportunity for the eliciting of tacit material came through guidedimagery exercises and drawings. The analysis of this information was extremelychallenging. Guidano and Liotti (1983) caution that although tacit self-knowledge isirrefutable, this is not knowledge that can be simply stored in the mind and summoned upat will. They suggest that images are reconstructed each time they are called upon, andthat "imagining is an active mode of information processing, which makes the elaborationof each image a unique construction" (p. 75-76). With this in mind, it is probable that eachimage generated by the women was imbued with many layers of meaning some of whichwere charted and some of which remained undiscovered. The nature and the meanings ofguided imagery exercises and the drawings were, first and foremost, considered in concertwith the clients during sessions. Their perceptions of the symbols they generated wererecorded and reflected upon. In addition, all drawings, including the TSTs were analyzedby means of qualitative ratings of individual drawings (Allan and Clark, 1983). Elementssuch as the amount of time the client spent on one aspect of the drawing, how they focusedon one particular symbolic component and so on were carefully observed, recorded, andconsidered.All of the sources of evidence contributed to pattern-matching, initially throughoutthe 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 aspattern-matching and explanation-building were adopted during data analysis (Yin, 1989).Further, Yin suggests that another method to minimize researcher bias is to "reportpreliminary findings while still in the data collection phase" (p. 65). Yin reasons thatimmediate reporting may help to minimize inadvertent skewing of data processed long27after collection. This method was also incorporated into the data collection and analysisthrough immediate (within 24 hours) transcription following sessions. Hopefully, theemployment of that technique helped to alleviate the temptation to avoid, or bury, contraryfindings through committing them to paper prior to the formulation of overall results. Thissystem also maintained a chain of evidence of both the session conversations and theinvestigators phenomenological reactions to each session such that an external observercould clearly follow the data collection process.Information was presented and analyzed in chronological order for the purposes ofclarity. Chronological analysis allowed for the clearest possible vision of participants'overall patterns of transformation through the course of session work. Yin (1989) suggeststhat "the ability to trace changes over time is a major strength of case studies" (p. 116). Theuse of pattern-matching over time, between and within each of the case studies, allowed foran 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). Tothat end, it is virtually impossible to be sure that a completely thorough analysis of the datawas undertaken. However, every effort was made to draw from a number of sources ofevidence, to guard against distortion of information by checking and rechecking theevidence from which the descriptive framework was developed, and to be mindful ofroadmaps and caveats described by previous researchers.28IV. CASE STUDIESThis chapter will present thorough summaries of the counsellor's entire relationshipwith each of the three participants. The cases are laid out sequentially, in chronologicalorder. A therapist's log, complete with observations about some guided imagery exercisesand the drawings, appears after each session. At the end of each week of sessions, asummary of one or more telephone conversations appears. Opportunistic sources ofevidence are included in the body of the session summaries.CynthiaSession 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 insome art therapy once before. She found it to be very threatening in that it had raised a lotof deep issues around her childhood sexual abuse. She talked about a previous counsellorwith whom she had worked. Cynthia said the counsellor was "obese and had no control" soshe didn't like her or have any respect for her. Cynthia also talked about the terrifying fearshe experienced around anyone who was obese in that "fat might be something that iscontagious. And that, they are so out of control. They let themselves be like that. Andthen I feel sorry for them because I think they must feel so awful about themselves andstuff. And it must be such a great shield to be that...fat. Like the whole world would bejust.. .it's a great way to keep the world out. I mean, even though they are fat people, mostpeople are not nice to them. And I am sure they are nice people. Like once you talk tothem. But the way I push people away, a lot of times can be so hurtful. Like I am sovenomous, 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 very29demeaning interview with a middle-aged lawyer. She ostensibly refused to talk withmiddle-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 thefirst drawing (Figure C1.1), "Kite", the second drawing (Figure C1.2), "The Coffin", and thethird 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". Cynthiapondered the significance of the coffin image and said very softly, "this is maybe like deadfeelings 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 theirassigned place. Then it looks like a nose. Two eyes and a nose. It just kind of looks like aperson's head. Everyone has to be a certain way.. .well you never really knew what way youhad to be. But, you knew it had to be someway, even though you didn't know exactly whatway you had to be", she laughed uncomfortably.We began the TST drawings with "How the world sees me" (Figure C1.4). Cynthiatalked as she drew, "there is a significant thing to it because I always see this part as beingokay. Up to about here (she points to the head and shoulders of the figure) like above thebreasts, from here up is okay. But from down here, it looks to me like, quite, big. It's quitelarge, it's like a not very proportioned person. I always think people think I am a totallyneurotic, totally like freaking out, like confused energy. I used to think that my boobs werelike this big", she exclaimed dramatically, making a large gesture. "Like I had to get themcut 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 mybody 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 Ilook in the mirror", I asked her about the patches of colour. She explained, "they are all30feelings Like when I look into the mirror sometimes I see real distorted images that aren'ttrue and I know they are not sometimes I think I am crazy. I look into the mirror and knowthey are not. It is impossible to have breasts that are like that. It is impossible to havescars on your body that are like that. You know what I mean? Like it's not.. .1 think, 'ohGod, you are going crazy'. Yeah. I think that it's like my mind has gone crazy. SometimesI look in the mirror and I totally feel like all I can see is black. And other times I just see aperson.. .like hollow. And other times I just see a person getting dressed.. .usually I whereblack. Like I don't really use a mirror that much. I don't always trust what I am seeing. Iknow that sometimes what I think I see isn't really what's real because I have becomedistorted in my views."In response to the final TST drawing (Figure C1.6), "My Inner Healer", Cynthiamused, "I am a very colourful person. I never thought about wise anything before.. .but Ialways think about it as a light. I little tiny light that grows and grows and grows but it isalways 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 visualizedthe little light inside which she described as "a lining." I asked the little light about thesignificance of her harrowing conversation with the middle-aged male lawyer. Sheanswered glibly, "the light says it doesn't really matter. He is just something that passedthrough my life that gave me an opportunity to learn something." The voice of the lightcontinued, "just do what you have to do to take care of yourself. Go work out. Eatnormally. Have friends. Phone people up. Be more social. Have more fun. Just go havefun. Just forget about it."I asked the light about Cynthia's attitude toward men. She responded, quiteassertively, "it's good because it protects me. A lot of men are not good. Well, it's not thatthey are not good. They are just not safe. They are quite bad." I probed further and sheconceded that In fact, men "are just people. They are not anything special. They are notbetter than you or worse. Just people."3 1After we completed the imagery exercise, Cynthia reflected that, "it's myresponsibility to take care of myself and I can't give anyone else the responsibility to takecare of me because then I will get hurt." I queried if this feeling extended to women aswell, she reflected, "well with women a lot of times they don't have this overpowering needto hurt people. Like they don't...their vendettas against life are usually more directedagainst 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 ofpassive/aggressive behavior: the juice drinking and the gum chewing, along with a need toslightly change session times, felt like a ploy to establish some control. I had theimpression that the food was being used as a way to create a safe distance between the twoof us. The time changes felt like some kind of test regarding my willingness to bend to herneeds. 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 herhair constantly and moved around in her chair a fair amount. She spoke at a furious pacewith ample amounts of humor, self-deprecating and otherwise. At times, I felt myselffeeling like I was at a pajama party listening to secrets out of school. Simultaneously, I feltas 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 almostas though being fat would, in some ways, be a welcome relief in that she could finallyeschew others' expectations of her beauty.With regard to her fear of middle-aged men. I found myself strongly suspecting adirect correlation between her father's sexual abuse of her when she was a child resulting ina feeling of powerlessness and her current experiences. Her contempt of men was sostrong it was almost palatable.32Figure C1.1. "Kite": The use of the orange and red suggest the presence of creativityand 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 appearedwilted or squashed somehow, unable to fully bloom.Figure C1.2. "The Coffin": The combination of the colours blue and brown maypoint to some statement about men and excrement. Interestingly, although the coffin maysymbolize death, it is not quite closed, suggesting hope for life. Cynthia also described thecoffin as a kind of door. Woodman (1982) discusses the significance of the coffin imageryin bulimics in some detail speculating that a coffin may be expressing a bulimic woman'sfeelings of "standing outside looking in, yearning for what other people take for granted.. .Inher aloneness, she fantasizes her emotions, but she has no "I" with which to experience realfeeling. Life does not flow through her" (p. 135). The black flower image may suggestsomething 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; alack 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 amouth. She has, however, made her eyes purple, which suggests a kind of spiritualpresence. Cynthia also did not depict hands, or feet, or a groundline suggesting a lack ofconnection 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 thepage and was intended to depict the "little white light". Cynthia was able to draw thisimage immediately and confidently.33Session 2, November 5.Cynthia began by expressing anger at her boyfriend who went to a concert withouther. She said she felt rejected and abandoned. She also related a dream she had thatmorning wherein she was different from everyone else and completely alone which madeher feel filled with "total despair." Cynthia broke down and cried as she explained, "I havealways felt this way. I always pick people that can not be counted on that are notdependable, that are not reliable, they are not. They are there one day but they are gonethe next and I have been trying to figure this out in the last couple of days. I have alwaysfelt, 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. Andthen I can't get accepted."Cynthia stopped crying and began talking about an awareness of a paradox in heremotions toward her boyfriend in that she felt she could have sex with him but that sheharbored a "huge resentment" toward him for going to the concert without her. Sheascribed an irrationality to her thinking yet she felt "deeply wounded" by it. We begantalking about the nature of abandonment; what it felt like, looked like. Cynthia drew apicture 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 tryand like this is me. And I sold myself out to these people my whole life. Like my, everysingle day of my life, that I have lived on this earth until I feel like today, right at this verymoment. 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 itisn't. And so I am on the bus and this feeling came over me like, 'fuck them'. YOU have somuch potential to BE. To be totally and completely accepted. I have so much potential toachieve. That's how I thought like this thing. And you are totally missing the boat. These34people are not who you need in your life! Like all of 'em. Like throw them out. Find agroup. Find a group of women. Get involved with women that are moving. Who areindividuals. 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 waythey are. But that's every person in my life today. Those are all the people that I am tryingto get my validation from."Cynthia then told a story of a big fight she had had that day with a female schoolcounsellor who had made, what Cynthia deemed to be, some insensitive remarks regardingsexual abuse. In telling the story, Cynthia cursed and swore and expressed great delight inhaving blown off a lot of steam in the classroom in front of fellow students. I listened andthen suggested her strong feelings may have centered around a fear of abandonment. Sheagreed and added that she often felt abandoned. She shored up her belief with an exampleof how she was shunned last year at a drug treatment center she had attended. She alsopointed 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 duringand after the fight. Cynthia acquiesced that two women did come forth and voice theirsupport of her. She then added the two women at her side in the drawing of her aloneagainst the world (Figure C2.1). We examined the difference between reality and herimmediate sense of reality. She questioned herself, "why do I see it as I am completelyalone?! 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 myneeds 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 aselective way; how she got mad at other women but chose not to show her considerable35anger to middle-aged men. Finally, we explored how her eating behavior may relate to hererratic ability to express herself. Cynthia reflected, "Yeah. Like I take it out by eating ordoing 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 likethe 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 wereunable to assert yourself." She replied, with an incredulous tone in her voice, "You knowwhat I remembered the other day? When I was 8 or 9, I used to be in this IndianPrincesses, from the YMCA. And it's like a group of men and their daughters. And Iremember one day, there were about ten fathers and daughters and we all went back totheir one man's home. And I said to the whole group of men something like, 'aren't we allgoing 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 punishedme. Calling me names, calling me a piece of shit. I told his secret to ten men! And I saidit right out loud. It's like when I look at men, I see them as people with no face. It's likethey 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 smalland they don't really amount to much. They don't really mean anything, they are just thereto let them blink, or move, or be aggressive. Otherwise that can't really put two thoughtstogether 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 feelabout them."I challenged Cynthia, "And yet, you told me in great detail, and with a great amountof anxiety, about the frustration you felt and the powerlessness you felt sitting in front ofthis, this lawyer, a man...with a gender for which you don't have any respect. So I amconfused." Cynthia stuttered, "I...I.. know but I don't understand why. Like I don't feelbetter than them."36We took some time to talk about Cynthia's childhood. She felt it was a very unsafeplace. She did not trust men. She did not trust women. She did not trust herself. Cynthiaacknowledged, "No. I could never depend on anything or anyone. I was always wonderingwhat was going to happen next. I was always scared to death that I was going to say thewrong thing or do the wrong thing or be the wrong person so when I could get away withsomething I would completely just go for it because I knew that I was going to get itanyway. And that is the way I have lived my life. Pushing everything and everyone to theextreme limit and in the back of my mind, I am going to get it anyway. And, in a way, Iwonder if today's scenario (with the school counsellor), I could feel that same feeling, like Iam just going to push this woman because I know she is going to snap.. .like, 'fuck you, like Iam going to push you and push you and push you until you own it. LIKE TELL ME YOUARE 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, "Iwanted to feel heard. I just wanted to feel acknowledged. I was going out of control, and Iknew that I was going out of control. I knew that I was completely losing it.. .1 knew that Iwas just pushing and pushing and the more she said, we have to move on.. .it was like no, Idon't agree, I won't follow those rules." Cynthia paused and then added, "Yeah, and then Ithought when I left there.. .1 can't even make a mistake.. .1 thought I can't even be myself, Ican't even make a mistake.. .1 don't know why I thought that. I can't be myself. I can't makea mistake like getting mad at someone in class."I asked Cynthia about the pressing need to be perfect. She began to cry stating thatshe simply is not like "normal women". I look around and everyone else is doing just fineand I am the fucked up one. I am the one who is a freak. That's how I feel. Everyone elseis over there and I am totally alone. I honestly feel like that.. .it's awful." Cynthia cried andlaughed at herself simultaneously, "Total self-pity!!"37I then asked Cynthia to further define what a normal woman was. She did not dothat instead, she began to describe her vision of what women, and, in turn, she, should belike, "I believe every woman has to like get out of the mold. Get out of what I have beentaught. Move away. Take who I was and completely move myself out. I don't have to weardresses. I don't have to look this way. I don't have to act this way. I don't have to stick myfingers down my throat to express myself. Like I shouldn't have to do that! I shouldn't haveto smile when I don't want to. Or not cry when I wanna cry. Why should I beembarrassed? When I am angry why can't I yell? Why do I have to feel I am doingeverything wrong?" Cynthia wept bitterly, "And I am looking at all these other people andthey are supposed to help me but the only one that can help me is me. And I know that butI 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 Iwas 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. Theywouldn't have used me.. .the minute they found out, that's a girl, I am owned. A boy is aman 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 shedescribed how they were shunned by everyone in society. And she spoke of how deeplymoved she was by their commitment to being true to themselves against oftenoverwhelming 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 andthey look so horrible and so sick and so weird with their beards and they don't' know how todress but they do it anyway because they believe that they are women, inside. You look atthem and think, my God, they are freaks of nature. But on a spiritual level, it's like they are38the strongest fighters in the world. To me, I see something in them. Them will sacrificeopinion 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 thosetransvestites wherein you will do everything to please everyone in the world exceptyourself." She agreed without hesitation, "Yeah, yeah. That's like my path.. .1 would loveeveryone 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 aview and that I hoped that by the end of the sessions she wouldn't care what my view wasanyway.We then moved on to a guided imagery exercise exploring her sense of spirit. Shestated that it felt like a breath. We pursued the breath which she described as a tightnessin her upper chest. She felt that her chest was storing "poison infesting her from otherpeople". She also began talking about how frightened she felt in that she was actuallybeginning 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 andit comes out and then I feel better for a couple of minutes and then it comes again. And Ijust feel so sorry for myself all the time. I am so sad. And I am all alone", she wept. Shepaused 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 othercolours in the middle of the spectrum. Also, I determined to continue to explore Cynthia'ssense of spirituality through the transvestites whom she saw to be glorious martyrs pursingtheir truth against all societal odds.39Figure C2.1. "The Separation": The colour blue (masculine?) was prominent in thisdrawing. The wall she depicted appeared impervious. Contrarily, the people she eventualdrew 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 ofcolours suggesting both hope and the genesis of a sense of self.Telephone debriefing, week one. Cynthia said she felt embarrassed about heroutbursts of emotion and anger in front of me because she felt she did not know me thatwell yet. She appreciated discovering that she had a lot of resentment toward women aswell 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 makean 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. Andshe asked to borrow a thesis, which she had noticed on the shelves in our therapy room, ontransvestites. 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 feelingsin the world. She was very worried that she would experience both fear and resentment ifshe did not feel heard. Cynthia was particularly concerned about whom, or what, tobelieve. 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 separatefrom their thing and my thing. Because I am never believing myself. Because I am neveron my side and I am always looking for THEM to validate me. I am relying on what theythink of me, not what I think of me. I have abandoned myself. Because I am looking ateverybody else to tell me who I am. I say who I am. No wonder I have been walkingaround in a state of total fuckin' freakiness and my whole life of total frustration and40resentment and anger of the world. Because they are all misrepresenting me. They onlysee a part of me. It's ME that has to see who I am." I took a moment to reflect and amplifywhat Cynthia had just said. She responded, grinning, that she loved that she had the "gutsto 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 hercounsellor was in a position of authority. I challenged Cynthia further that she was seeingsomething in the counsellor that represented a part of herself that she did not like. Cynthiaresponded that she felt the counsellor was "a total victim. My biggest resentment of her isno personal power...it frightens me to be in a room with people like that". We discussedthe irony of the intimidating role Cynthia assumed in the class room in relation to hercounsellor, which was somewhat like the intimidating role assumed by the middle-agedlawyer in relation to Cynthia. We explored the possible connection between a feeling oflack of personal power and wanting to binge and purge around those feelings. She becamequite tearful around feeling guilty for having "embarrassed the counsellor and taking greatjoy in that. I feel so ashamed." We talked about how Cynthia could be kinder to thecounsellor, and more forgiving of herself. Cynthia suggested one way of helping herselfwould be to define better boundaries. She came up with the idea of a big door with ascreen in the middle of her forehead so that she could fully protect herself (Figure C3.1). Iasked her to draw (Figure C3.2) a close up of the filter holes in the screen so that she couldfeel very safe about her level of control and protection of her emotions. She chose theflesh tone pastel to symbolize the ability to listen without judgment; the green pastel tosymbolize kindness and warmth; the orange pastel to symbolize creativity; the blue colourto symbolize supportiveness; and the purple colour to "acknowledge the weak parts ofmyself 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-barrectangle 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 to41feel ashamed of the part of her that was big so she only used muted, light colours. "As awoman I did not feel allowed to be these big colours. .1 had to be small...the reason I had tobe 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 twodifferent perspectives of the same coin, Cynthia was able to consider, for the first time, thefeelings of the counsellor.We finished by talking about the leap of faith between knowing something andliving it. Cynthia felt she was learning a lot but was feeling very uncertain about living whatshe was discovering about herself.Therapist's log, session 3. I felt as though Cynthia was increasingly trusting of me. Ifelt as though we had established a good therapeutic alliance. I found myself genuinelyappreciating her feisty spirit and her sense of humor. I still found myself feeling slightlywary of her possible passive aggressiveness regarding the starting times of the sessions. Icouldn't help but wonder what part her testing of my willingness to be flexible regardingtimes was simply a test of her ability to feel in control with me. I resolved to happily goalong with her needs.I found myself marvelling at how different Cynthia was from time of the outset ofour work together ten days ago. She seemed markedly less moody. She also seemed toexude more energy.I reflected that we had spent a lot of time exploring her strong views: her black andwhite way of seeming the world.. .it was very interesting to work on the drawings with herand see that the colour she chose for the filter was GREY, yet the microcosm of a filtersquare was filled with many colours!42Figure C3.1. "The grey filter mask": This masks looked like a fencing mask but shedescribed the broad edge as a door and the bum as a door handle. Both of these detailswere on the right (male) side.Figure C3.2. "Closeup of filter": Interestingly, the rainbow of colours ultimatelyformed the shape of a C, the first letter of her name! I wondered about the relationshipbetween the rectangular-shaped colours in this drawing and those of the living roomdrawing from the first session. Cynthia cried when she drew today, she said she was feelingsome shame.Session 4. November 12. Cynthia arrived today in a very good mood again. She wasvery 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 thata short rehearsal conversation we had had helped tremendously. She also volunteered thatshe had not binged or purged since she started these sessions. She also expressed concernthat 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 themost 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 thestreet corner".We moved into talking about the difficulty and vulnerable feelings stirred up in herwhen she contemplated her childhood abuse issues. This discussion led into one about theformative stages of her bulimic behavior. She described the worst bulimic episodes whichoccurred for her when she was fifteen at which point she was binging and purging up to 20times a day. The binging would literally unleash memories which were so awful that shefelt compelled to purge out the feelings. "I would eat and have to get it out and it felt sogood to get it out. I was an alcoholic and a drug addict then too. But the binging was sopowerful - to stuff all that food into my body. I would make charts as to how long it would43take to be digested by reading books and going to the library (to know how long she couldbinge for before the first of the food eaten started to metabolize). I used to have chartsand 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 feltashamed. 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 yearsold I said to my sister, "If it's the last thing I do I am going to suck those fuckers dry.. .(shewanted to break them financially) It felt very powerful because.. .where did the food go?.. .1don't know! It was like I could be totally defiant. I can remember them not having anyclue and I remember telling them I was doing this and couldn't stop and they laughed atme."Cynthia explained that the food was different in that it was the first and foremostway of making her parents pay...the drugs and the alcohol were a way to get out of thehouse but they were not as rewarding because they were more socially acceptable ways ofacting out. Cynthia giggled, "Who wants to be with someone who sits in their closet in theirbedroom and pukes all over the house?"For Cynthia food was her first and remained her last addiction. It began when shemet a girl who threw up. Cynthia's first thought was, "this is such an excellent way to fuckpeople up. The next day I was shoplifting food and eating the whole house up." Shepaused for a moment and then added in reference to her parents, "but I couldn't throw upyet because I didn't hate them enough. The first time I purged, I became crazy. And itnever seemed like an eating problem."Therapist's log, session 4. The general mood of the session was energized. I feltvery happy for, and proud of, Cynthia's ability to resolve her fight with her school44counsellor. Cynthia appeared to be very please with both her handling of the situation andthe results of her well-planned efforts. I was really delighted that Cynthia receivedacknowledgment for her hard work. She seemed genuinely thrilled at the realization of thepossibility of her own positive power in the world.Telephone debriefing, week two. Cynthia related that she was experiencing moresexual abuse memories and that this was really frightening her. She felt this week like shewas not sure she wanted to come to the sessions for fear of what she might haveinadvertently discovered.Session 5, November 16. The moment Cynthia arrived, she asked to use a phone sothat she could phone a friend about whom she had been worried. Once she was confidenthe was alright, she began talking about a Narcotics Anonymous convention she hadattended over the weekend. She had been particularly moved by a courageous woman whohad 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 afraidto do so. I asked her about the presence of fear around a responsibility and a guiltregarding somehow causing what had happened. She nodded wide-eyed and said slowly, "Ialways think it's written all over my face.. .like all the awful things. And I always think I amreally dirty and bad. I feel so dirty."We spoke further about the NA woman. Cynthia recalled the woman said "she hada frozen screamin her throat." I asked Cynthia if she felt like she had a frozen scream inher throat. She started to cry, "I can't escape going through the pain of my past. My otherfear is if I don't do the work then it's going to come out all sideways and crazy". She gavean example stating that she had contemplated going back to the street last year. Thisdesire had nothing to do with sex, she had wanted the feeling of power back.45I asked Cynthia to draw a picture of what her body felt like when she was on thestreet (Figure C5.1). She took a long time to render the drawing. She did not talk whileshe drew but rather concentrated fully on the task. Once she finished the drawing, sheannounced that she was feeling "bleakness". Cynthia elaborated explaining that "the fourblocks of colour are like a banner to the world and an internal banner as well - across myheart. And you have to be out there, you are big, you are open and you have to be sexualbut you can't really show too much. You can't show any positive attributes except in yourbody. You can show spirit but only in anger. I smiled but I knew when to stop and if youdon't you'll be a victim.. .it's like the way spiders eat their prey.. .they can't help it. It's justthe way it is. If someone picks up on your vulnerability, they hate you because they haveto."She went on to speculate that the colours represented her family members: thegreen represented her, the brown symbolized her sister, the black was her mother, and herfather was represented by the red. She identified that she "hated her mother the most". Iasked her if her intense hatred had to do with a suspicion on her part that her mother knewher 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 toher all the time." Cynthia continued, "When I try to thing of something that was goodbetween me and my mother and my father and my sister, nothing was good. Even if theincident was nice, what I have to pay for that was horrible.. .so nothing was good. And whenI think of my sister.. .it's mostly just sad, just sad... sad, sad, sad. At four and a half I wastaking care of my sister...my mom was sleeping. I resented her, I didn't know what to dowith 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 shewas eight years old, her father came into her bedroom, and although she repeatedlyshouted "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 whole46body.. .1 lurch forward.. .1 could kill someone. That is how I have actually felt. I could goinsane." 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 wasa way of saying "yes". And it was a way of being left alone. She elaborated, "when youeat.. .you get all this armour.. .1 eat with my mouth open.. .it's tastes like shit". She gleefullydescribed that she loved to eat without any attention to manners especially since her fatherhad 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 ofher 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 whenshe herself was still very young. I did not sense she ever was able to simply be a child. Ialso wondered about her continuing to step into that role with people like her suicidalfriend. It was a role she seemed to know well.I was also interested in her dance with the prospect of exploring her childhoodsexual abuse issues. She seemed so strongly drawn to the precipice of those memories andyet 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 femalefertility and yet it is depicted in the colour brown; the colour is excrement. The red mayembody 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; thecolour she ascribed to her mother. The only island of health maybe the colour she reservedto describe herself: green. However, Cynthia did not interpret green as healthy, she saw ita 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 also47squiggled and confused. They did not suggest any sense of real control, order, orauthoritativeness.Session 6, November 19. We began by discussing Cynthia's overwhelming feelingsof intimidation whenever she found herself having to interact with middle-aged men inpositions of authority. She explained, "I don't feel as inadequate around men as I doaround women. When a man raises his voice and says the way it is going to be, I get reallyscared. When women do that, the opposite happens, I know I could hurt them. I am notafraid for my life...even though my mom was physically abusive, I don't get the same thingfrom women as I do from men. I have been sexually abused by men and by women, but myfather never hit me: my mom hit me."We agreed to undertake a guided imagery exercise wherein we sought out hermaleness within in an effort to better understand the intimidation she felt around certaintypes 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; andphysical strength. When I asked her cite her male gifts, she was initially stumped reportingonly that her body felt, "kinda sad". Eventually, she was able to identify some positive maleattributes which she felt she embodied: the ability to be different in different places, be achameleon; the ability to get things done in order; the part that knows there's a time and aplace 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. Shesaw them as a vertical line. We asked the line for advice regarding how to deal withintimidating men. Cynthia reported, "they say the reason why I am like that is because I amafraid. I think I have to do some work around my (long pause).. .1 have to do some workaround being a sexual abuse survivor. I don't have the walls and the masks anymore to hidemy fear. Before, it didn't happen. I would not talk to them or be rude to them or makethem not like me."48When we finished the exercise, Cynthia reflected on her reactions to men, "I couldlive in the world very easily without men. They are useless. It's hard for me not to be angrywith men when I see what goes on in the world. And it's hard for me not to be angry whenI know what happened to me. I feel repulsed by men. The look of them, the touch ofthem, 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, "Ifeel like I am contaminated. I am contaminated by their sperm, their bodies. Theycontaminate the air. They contaminate me everywhere I go. They look at me walkingdown the street I am contaminated. They ruin me."I asked Cynthia about what it was like to have sex with her boyfriend, Robert, "I feelashamed. Gross. There's something about sperm.. .it feels very relieving to me when Ithrow up...get it out, just get it out. Sperm. I can not handle a man putting sperm inside mybody. 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 onlything is then I feel like an empty vessel having to fill myself up again because the only way Ican protect myself is with food. And without it in my body I am totally vulnerable. If Ipuke and go work out, I am totally afraid...where if I have eaten and I don't throw up I feelashamed and I feel fat but I don't feel like someone is going to attack me. What's moreimportant? So now my desire to throw up is not so great because I know what the outcomewill be but sometimes it's worth it. It's like being on a bad trip. It's like doing acid for allthose years and then suddenly it turns on you. It all turned on me." Cynthia finished ourdiscussion by describing wanting to get something else, besides sperm, out of her body: itwas a monster represented by "big faces, big people, loud obnoxious, ungraceful, knockingthings over, so uncaring, I always thought my parents were so stupid".49Therapist's log, session 6. In spite of the very challenging and intimate material withwhich we dealt, Cynthia remained very energized and presence throughout the session. Iwas struck by her courage and by her desire to get well. I found the guided imageryexercise exploring Cynthia's male qualities to be very telling. I suspected if she couldreclaim her maleness, some of her dirtiness feelings might be able to dissipate through aself integration.Telephone debriefing, week three. Cynthia marvelled she had never before talkedabout the things we talked about this week. She said she was feeling good; that she wasstarting to feel "more stable". She was also noticing changes in her behavior, feelings, andpatterns. She said she had not purged since we had started working together; a durationwhich she described as a "long time". She also identified that she still had not exercisedsince we had started working together.Session 7, November 23. We began by discussing how Cynthia felt that hermanipulative behavior had always gotten her in trouble. She felt she was constantlymanipulating people to get what she wanted. She stated resolutely that she did not want tooperate 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 andher sense of control. Cynthia began excitedly talking about the high goals she had forherself and that she was beginning to believe in herself. She said she daydreamed aboutbeing successful, and believed that she had the ability to do so. I asked Cynthia toelaborate on the difference between short term thrills and long term thrills. Sheimmediately answered that the thrill was in "having a goal, setting a date, doing theresearch and getting what I want. The thrill is in doing the steps... the thrill is when peoplesay 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 a50thrill to be in crisis. It's like a punishment. You know what motivates me is fear, fearmakes me eat, throw up, exercise, see my friends.. .fear of rejection, being fat, beingunbeautiful... looking in the mirror. My body starts to manifest things that aren't reallythere. I know it's not really true but it just starts to get bigger, folds of flesh, stretching, Ican 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. Sheexplained, "I don't feel safe when I get out of aerobics. I don't feel physically safe...I feellike 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 forher between aerobics (female) and stairmasters (male). She stated, "In aerobics you haveto be perfect. It's about looking good and being really coordinated. It has a lot to do withimage. Women compare with each other and stare at other women's bodies in ways thatsuggest they aren't good enough. If I am in the middle of an aerobics class I can't be surethat I am not going to run home, binge, and purge. Because looking at other women'sbodies...comparing myself, punishing myself.. .1 feel I have to be thinner. I go home, feelingtotally lost, eat big time and puke. It's just insane thinking.. .but who's standards am Iworking 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 wantto look like a tit-less, ass-less robot. I don't want to look that way I want to look like awoman.., that's what I need to tell myself."Cynthia paused and reported with a knowing smile on her face, "The little light isgetting this intense head rush". We moved into a guided imagery exercise to talk more withthe light. At first, she has trouble locating the light in that she felt it was hidden behindsome food. I asked her to dust off the food, which she did and then said, in a little girlvoice, that "the light was afraid of being assertive". After some coaxing, the light51volunteered that it felt Cynthia spent too much time in her mind. And if she did access herfeelings, she was unable to actually think and feel at the same time. She observed that shewould like to be more than "black and white". She paused to reflect for a moment that shedid not think about herself as fat on the weekend. I observed that her weekend experiencesounded 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'tmatter."Cynthia suddenly exploded, "why is everyone else's 'appropriate' so fuckingimportant? Their rules are so much more important than mine? That's why that stupidlawyer thing happened. I am selling myself out. I am mind reading. I could stop askingpeople what their opinions are". Suddenly Cynthia noted that the lawyer was usefullearning for her recovery. She appreciated that he helped her to listen to how she felt, "if Iwant personal power, then I have to keep it not give it away".After we completed the exercise Cynthia brought up her experience of the sittingbeside fat women on the bus. She observed that she no longer felt afraid of them, but feltcompassion for them and wanted to give them Overeaters Anonymous pamphlets as a wayto offer help.Therapist's log, session 7.I was fascinated with Cynthia's experience of vulnerability and lack of safety aroundcertain types of exercise depending on the fullness or emptiness of her stomach. It felt asthough, without the "armour" of food and the feeling of heaviness, she did not have enoughprotection 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 atray which she had noticed in the Counselling Psychology faculty staff room. She appearedvery upset. After scarfing the food she had stolen, she asked me to bring her some more52since 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 atan 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 haddefiantly jumped to the defence of the woman which, in turn, incurred the wraith of theburly man. He screamed at Cynthia, "like an animal", and shouted threats and obscenitiesat her. Cynthia was so frightened by this man that she left the meeting. She felt like hidingand binging.Instead, she chose to talk with some people about her experience and she worked onher resume for several hours. Things changed when she went home that night and told herboyfriend about the man at the meeting. He became very angry and his anger deeplyfrightened Cynthia. She said she started to feel like she had "been raped." She was shakingand crying, "I started having all these flashbacks.. .all the anger feelings, my parents werelike that, I remember being raped and the faces were like that, a couple of guys that wereangry...a guy I lived with was like that, trying to intimidate me with physical force. I havebeen threatened so much. When that guy was threatening me I just stared at him. I felt soweak. I have to look at my part in it too. Now I feel like a piece of shit. I feel so weird. Ihate 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 veryscary thing. And then having these people support me. I could have had a million peoplesupport and it wouldn't have bothered me before. It makes me really angry when peopleacknowledge me."Then Cynthia spoke more about what had been stirred up in her as a result of herconfrontation with the burly man. She roared, "I am just violated; the same way I always53felt when I was younger. Except it doesn't feel comfortable anymore. It doesn't feel safe. Ifeel RAW. I feel on edge. I feel like my behavior is weird. I talk constantly. I am kind offake. I feel like I am not real. Part of me does not want to accept the fact that.. .1 keep onfeeling like it was my fault that man hated me that way. It's something I put out in theworld to make him do that to me. Then there's this other part... 'how dare he hurt thatwoman?' Then another part says. He is a lot bigger and stronger than you, and she doesn'tneed other people to take care of her she can take care of herself. And then I just feel likea fool. I feel like In some way I made him treat me that way. I keep on looking around forpeople to blame me for that."Cynthia began to cry, "What am I supposed to do smile? I want people to leave mealone. I am not going to sit there and be open bait. It's just like I am not safe. I don't feelsafe. I can get beat up at an AA meeting. I walk down the street and some guy is going toattack me. And the hatred. That's what really got me. His hatred toward me. Men hatethem (women). Men batter them and bruise them and rape them and hurt them all thetime because they hate them. Men hate women."I asked if Cynthia if she felt her father hated her. Without missing a beat she shotback, "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 shefelt her father's feelings about women might have been ingested by her somehow. Shereplied that her father's thoughts were throughout her being. She reflected further on herfather, "I think my dad wanted to be loved so much but he was so angry and he was soconfused. 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. Mymom, my sister, me. To me. He repulses me beyond belief. The sound of his voice on myanswering 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, I54breath. 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 hersister. She talked about needing really strong boundaries, that she wanted him "to die", andyet she felt "guilty" at not returning his phone calls. "Then I thought why should I phone aman who has sexually abused me. He makes me so SICKENING. He makes me soUUUUUGGG...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 threepictures (Figures C8.1, C8.2, and C8.3) without speaking. Once they were completed, shebegan to talk, "the first one I was thinking that I wouldn't think and I wouldn't feel. I feellike I am in a jail cell. And it's like nobody can really see it and I am even wondering if it isthere but it is very much there. The whole world is like a jail. It's like living in hell. Itseems like they are always there. Sometimes they are not there as much. I don't think it'spossible for me to live my life without them there. I don't think it's possible for a woman tobe free. I don't think I will ever be free. I will always have to play second fucking fiddle tosome man. I will always have to suck some cock somewhere along the line. It doesn'tmatter what I do. I have a decision. But even in the decision, I always have to sacrifice myintegrity so I can eat my food, do this, do that. I always have to hurt somebody orsomebody is hurting me in order for us to get what we want. It's always a catch 22. Nothingis 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 herfeelings. Cynthia discovered that the light was "very small and pink, feeling very scared". Iasked Cynthia if she could encourage the light to spread pink thorough out her body. Shewas able to do this and reported feeling more peaceful and more comfortable. I askedCynthia if the light had any suggestions...she answered, "to stay calm, and pray. Pray toGod and ask God to take care of it for me 'cause I can't do it."55Therapist's log,. session 8.Cynthia was clearly extremely agitated, experiencing both an immediate emotion inresponse to the confrontation with the burly AA man. I was stunned at how scathinglycritical Cynthia was of herself. It was as though she felt responsible for the burly man'swraith; as though she felt responsible for her father's sexual misconduct. I felt as thoughshe 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 ablack line scorched through it, permeated by a stain of brown. The drawing felt very rawand angry.Figure C8.2. "Flower behind Bars": This drawing felt childlike. It depictedsomething that is normally associated with beauty and joy and yet the image wasimprisoned. The colours at the top of the picture looked like storm clouds and they toowere behind bars.Figure C8.3. "Third Drawing": This piece felt like the storm had broken. Pink andpeach colours emerged through the work framed by remnants of the storm colours ofbrown and red. The colours were still encased, however, by black, vertical and horizontallines.Telephone debriefing, week four. Cynthia said she had learned that she does notwant to be a victim anymore. She also expressed that she was learning to take care ofherself. She described crying for "two hours straight" on the weekend. She experienced aresurfacing 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 sentimentemanated from our talk with the "little light" which told her "to pray". Cynthia thenconfined that I am "the only woman" with whom she has ever connected and she is worried56about what will happen when we are finished. Finally, she raised the issue of her anger ather father. He phoned on the weekend. And she felt furious.Session 9, November 30. Cynthia appeared uneasy today. She began talking aboutwhen 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'twant, "dirty feelings of loneliness, insecurity, fear...a lot of times loneliness, or if I havemade a mistake. But I feel stronger...I have experienced a real frantic feeling of neverwanting to feel the purging feeling again. It happened the day I met you. The day I signedthat paper. Saying, okay I have an eating disorder was a big thing. The second thing wastalking about it, saying I have an eating disorder."Cynthia moved into talking about how difficult it is for her to talk intimately withwomen, "It is more frightening to be intimate with someone that to be anything else." Thenshe 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 doublechecked on the therapy program she had set up to follow our work. Cynthia said she hadcalled 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 sheseemed to be working toward that now. Cynthia quickly answered that it was because sheknew 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 whomshe felt had really let her down. She was furious that we had done so much in such a shorttime and so little had happened over a year with her past counsellor.Cynthia appeared very unhappy and agitated. I suggested we do a guided imageryexercise to help her feel more centered. As she moved inside, and she immediatelydiscovered a big lump of anger and frustration in her stomach. I asked Cynthia to breathdeeply and image a funnel from her feet to the center of the earth through which poisoncould move when she exhaled and from which fresh, pure energy can emanate when she57inhaled. Cynthia reported feeling much better. I introduced her image of pink light intothe exercise, asked it to sterilize and heal any areas that had poison in them, and to spreadpink light throughout Cynthia's body so that she could recognize and love herself and feelcentered in her power. Cynthia calmed down considerably. She finished the exercise andreported feeling much happier.Therapist's log session 9. Due to work constraints, Cynthia was unable to meet meat 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 herprevious counsellor. I confronted her about the possibility of the drug and alcoholcounsellor being a projective screen for her fear of abandonment by me. Cynthiaadamantly denied that suggestion and determined that she was in fact angry at herself fornot 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 tosuck on several of them throughout the session. We began by going over the plan for herfuture therapy. She took a moment to tear into her past counsellor again. She alsoinformed 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 threwup for the first time since we began seeing each other after our last session. She said shefelt 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 shehas thought about this but that she really did not feel that was true. However she thenimmediately talked about how far she felt she had come during these sessions especiallysince she had been in "desperate need". She felt the counselling work she had done in thepast "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 workingto find her a solid therapeutic path for her to follow when we had finished, "when you said58it, 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 saidanything, that is exactly what would have happened."We moved onto to talking about the nature of her upcoming treatmentopportunities and she registered her great fear that she might have to work with men. Sheannounced that she would be much better off if she never had to see or deal with menagain. 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 existentwithout men.., women don't do the same thing."I asked Cynthia about was going through her mind when she binged and threw up onMonday night. She answered, "It was like I was isolating myself. I couldn't reallyunderstand why I was doing it. I think I was really, really angry at the fact that...my drugand 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 wouldhave files on her. She responded, "When I look at you I get attention. When I talked toher it was like she is staring out the window. I know you know what it feels like. I knowthat. But with her I don't. I don't really feeling like you are leaving. I feel like I am goingon. I am not resentful it is not going on anymore. I don't really feel like it is over. What Ihave been angry at is myself. I was going to leave myself open and not get any helpafterward. And it makes me fucking angry that in six weeks I could get more in a week, inone session, that I ever got from her (the drug and alcohol counsellor). I think maybe Icried twice in a year with her. I never got the right help and it makes me mad. That is oneof 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 counsellorand her mom. She noted that she broke off relations with her mother around the timewhen she first started seeing her old counsellor.59Cynthia began crying about the "incredible fear and total change" since she madethe decision not to get near her mom. "It's just that leap of adulthood even though I feelbetter that she is not in my life. By saying that it is over (with her mom) all the otherabuses disappeared too. I started to support myself. It was a good thing but it is reallyscary. I am the one that is doing it. There is no turning back. There isn't a mother to fallback on."I asked Cynthia about what a perfect mother would have to do to help her. Sheresponded quickly that she did not want anything to do with any kind of mother at all. Shelaughed uncomfortably, "the thought of having one is nice. But the responsibility of havinga mother is too much." Through tears Cynthia shouted, "I just don't want one!!! I don'twant 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 Iam my mother inside of me it makes me ill!!! I don't want that even if it is good. I reallydon't. I DON'T WANT ONE!!! It's like a thing, it's like a lacking think. When I let go ofher 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 allsituations. Who is totally fake. A person who is really strong. And now I am reallyintimidated by men, by this, by that."I commented that those aspects of her mother sounded like a warrior. She agreedwholeheartedly. I asked her to draw a picture of the warrior (Figure C10.1). As she drewshe talked about fighting back at her father but that it was not very successful. As soon asshe finished her drawing she began to interpret it. She saw the orange as creativity; the redas a healthy anger, "It's not a bad anger, it's a good anger"; and the blue, green and purpleas "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, Istruggled in my life, but my mother struggled and my grandmother, and her mother...and so60we have something inside of us is very powerful because we came up out of struggle. Thepain turned into something that made up special."Therapist's log, session 10. I felt it was no coincidence that Cynthia purged for thefirst time since our sessions began following our last session wherein we spoke abouttermination. I suspect Cynthia was worried about our union dissolving before she feltready for that to happen. I was also considering another possibility which was theemotional storm stirred up in Cynthia by the burly AA man. Cynthia was very concernedabout 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 fantasyabout mothering let alone actually consider the possibility of accepting that from anyone inreal life. It felt like she protested too much.Figure 10.1. "The Warrior": Cynthia drew an image of the part of herself she lostwhen she stopped communications with her mother. The image was shaped like amandala. It was depicted in strong, bright, rainbow colours. Interestingly, the emotion ofanger was rendered as distinctly separate from the female components of the drawing.Telephone debriefing, week five. Cynthia reported that she was feeling better allthe 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 offights with her boyfriend. She said she felt like a "bad person" about her boyfriend. Shestill felt very shaken by the AA experience. In general, she felt very frightened at theprospect of even looking at men let alone talking with them.Session 11. December 7. Cynthia arrived eating a cornpuff snack. I begin by finallycommenting that she had arrived at the last few sessions with food. Cynthia replied thatshe has not been eating lunch lately. I asked if it may also have anything to do withneeding to keep emotions at bay. She chortled, "Obviously I eat to hide from my feelings.61If anything is on overload I eat." I commented that she didn't eat like this when thesessions began. She shrugged that she did not have very good eating habits. She also notedthat 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 lookback 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, Inever allowed anyone to care about me. If somebody was showing caring, I didn't like themanymore." I commented the cost of accepting care had been too high...she agreed. Shethen talked about Robert and how difficult it was for her to experience him getting madover 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 withRobert might have been veiled attempts to push the intimacy away. She agreed. I asked ifthe intimacy with Robert was the first she had had with a man since her dad; it was. Iasked if this could have been stirring up those unresolved memories. She identified, "I amdealing with all the yesterdays. It's not about him and me. It's about me and somebodyelse. It wasn't just my father who abused me." She described Robert reaching for her in asexual 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 Cynthiaresponded 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. Myrecovery 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 abouther issues with her mate. Cynthia felt she needed him to be strong. She felt she needed tostay away from him for a while. I asked if there was a connection between deciding not tosee Robert, her school finishing, these sessions finishing, and looking for a job. Cynthiaacknowledged she had been thinking about that.62We summarized some of the work she had done in our sessions including: beginningto know what was best for her at any given time: shoring up her boundaries; being able toexpress her feelings more openly with people; and developing useful, empowering, dailytools like the imagery of the little light.Then out of the blue, Cynthia announced she had called her estranged sister for thefirst time in six months. She explained, "I needed to hear her voice. I always have feltresponsible 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.., shesounded so together. She is driving a car. I am really jealous of that because I am totallyafraid 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 parentsweren't so abusive. Maybe I am making this up.' We had a really bad sibling rivalry. Mymom pitted up against each other."We determined to do a guided imagery regarding going inside and exorcisinganything inside of her that did not feel like the real her. Cynthia moved inside andimmediately gravitated to her brain where she saw cigarette smoke-like blue, grey fog. Shereported "it is a downer.. .it's depressing me. Because I want to have everything I want. ButI am not getting it.. .negative thinking." I asked her what she would have to do to burn thefog off. She wanted to give it away to God, who is 'up there'. She determined she couldgive 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 outcomeinstead of letting it happen naturally. I am ripping myself off. Not using the light, I willalways be in the same place." We focussed on the fog being sucked away to God. Thistook a few minutes. Cynthia reported that the light and God are different but that they aremade of the same thing. She determined the light was closer, and was a pale blue colour. Iasked Cynthia to allow the light to fill the space in her brain that has been left by the fog.63She did this and it enabled her to feel safer. She also reported that she was making herbody warmer by generating energy in her solar plexus.When Cynthia finished the exercise, she began talking about wounded peoplewalking the face of the planet causing so many problems. I asked about the food. Shereflected, "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'salmost like telling my father that he is right." I asked Cynthia about her binge/purge lastMonday. She answered frankly that she did it because she felt "afraid"... .now it's hurry uplife".Therapist's log, session 11.  I was not in the least bit surprised that behaviors such asthe binge/purge, eating in the sessions, and a little stab at starting smoking again havecropped up at the end of our work. They felt like hollow efforts however. Cynthiaappeared to be thinking ahead about our sessions ending. I sensed she was not sure if shewas ready to fly on her own, to trust her instincts without my support shoring up hermixture 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 ofsessions. Cynthia asked if I could continue to work with her. The component of siblingrivalry came up in this session. It felt as though Cynthia was irked by her sister's progresswhich 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 thatCynthia had phoned and left a message saying she felt unable to come for the sessionbecause she could not bear goodbyes. Ironically, this was the last day of her schoolprogram as well. I phoned Cynthia to rebook an appointment and she explained she would64be busy from here on in and would not be able to come. I decided to make a concessionand go to her house to be able to terminate properly.Cynthia began our last session by talking again about how she was uncomfortablewith intimacy, especially with other women. Cynthia explained that she had really actedout by pushing people away at her school ceremonies earlier that day. She reported shewas 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. Sheelaborated, "It's like I have to be an adult. I have goals. I have dreams; having to bemature, have goals, aspirations; having to give up my mother and my father to heal is amature thing. Standing up to them. I stopped the abuse. I did something for myself and itdepresses me. There's a lot of guilt attached. I get confused. Maybe I should let bygonesbe bygones."Cynthia was pleased she had a job. But she added, "I am in pain. I am totally madbecause I have to change. I am totally scared." I asked about how this pain was differentfrom being on the street or when her dad abused her. She mused, "It's like ...I didn't reallyhave pain. It was dull. That's all I thought I deserved. That's all I thought I could do. Iliked 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 Iwanna 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 thatwhite light now. You wouldn't believe it. I think about that white light all the time. One ofmy affirmations for last week was, "I, Cynthia, believe in my white light. I get upset and Isay, 'white light.' I know that it is there. That was so valuable. Everytime we did that. Ifeel like I have changed. It's like I am much more than just me. It's like there is a wholedifferent 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. It65very 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 sometimeswhen I am doing it I get a smile on my face. It's like the only place in the world where I cango where I can really smile. Where it is like glad. I don't know. I never really experiencedthat 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 imageryexercise was. She talked about the day she met me. She felt she was at the end of her ropethinking of "living on welfare and eating salami. I was so desperate." She was tooembarrassed to admit to being a bulimic at the OA meeting. Earlier today, Cynthia hadstood up in front of a whole group and admitted she was a sexual abuse survivor. Wemoved on to the TST exercise.Cynthia interpreted her first drawing (Figure C12.1), "How the world sees me", "Iknow the world sees me as loving, a spark for life, a zest (the red); the middle is soft andenergetic (the yellow); black is the shadow part of me. The red is my anger for life, not badanger.. .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 peopleabout five minutes to see the red."Of the second drawing (Figure C12.2), "How I see myself when I looks in themirror", Cynthia said, "I see a person who displays pain and anger.. .acting out right? (thewiggly 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 ofdarkness (brown). The pink is pain, it's different, like growing pain. The blue is what Iwant to show people: normal, alive, and fun and zest and energetic and fighting. I thinkthis is me." In reaction to the final TST drawing (Figure C12.3), "My Inner Healer", shelaughed gleefully, with sparkles in her eye, "it's alive". The white light was, in fact, arainbow of colours.66Therapist's log, session 12. I felt a bit frustrated by Cynthia's last minute decisionnot to come to the final session. I also felt compassion for her fears. I shored up herdecision through complimenting her on listening to herself and taking care of herself. Partof me felt manipulated; part of me felt that my willingness to go to her was what sheneeded 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'tmean an end to problems. She recognized that it may even mean MORE problems in thatthings were no longer masked. As a result, more feelings and more awareness may comethrough. She was realistic and philosophical about the discussion.I was impressed by the depth of her appreciation of the white light. I wasincreasingly struck by her reports of conversations with her version of God - and the peacethis seemed to bring her.Figure C12.1. "How the world sees me": The image depicted looked like atriangular mandala - somewhat like the inner healer image drawn in the first set of theTST. The pink/purple core felt like a sort of feminine/spiritual symbol of some sort. Thegreen 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, perhapsprotective, anger.Figure C12.2. "How I see myself when I looks in the mirror": This drawing felt quitedifferent from anything Cynthia had done before. There felt like a wonderful mixture oflight and dark colours. It felt as though Cynthia was welcoming in her whole spectrum ofemotional 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 colourwas quite different from the other drawings. The use of flesh tones were new. The67placement of the human flesh tones was interesting (the inside and the outside). Joyousyellows were also echoed on the inside and the outside of the image.Telephone debriefing, week six. Cynthia described herself as feeling very goodabout herself and her world. She reported feeling "much more human.. .if I overeat, Iovereat. If I throw up, I throw up. I am human." Surprisingly, and to her delight, she hadstarted to see her estranged sister on a regular basis again.Regarding our work together, Cynthia said that she felt very cared about and thatshe 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 amreally feeling like I am becoming a woman. It's a grounded feeling. I welcome theresponsibility. It is achievable. It is so nice to be relied on, be respectable. I am nowthinking I might be ready to work with a male therapist."SonyaSession 1, November 2. Sonya arrived chewing gum. She immediately denouncedher drawing ability but gamely began the warm up drawings. As she drew, Sonya talkedabout 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 whenshe had not even been able to leave her neighbourhood. Sonya also talked about herboyfriend, Jason, exclaiming she appreciated him because he wouldn't let her "play gamesof manipulation." Sonya talked about her weight; about how much she had binged andwhat a terrible day she had had. She explained, "I feel very very fat, I am still binging allthe 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 speculatedthat she ate especially when she felt her security was threatened in anyway, adding that shewas in a business with no security.68Sonya finished the first drawing (Figure S1.1) and reacted to it, "I started to feelreally funny when I did this (points to the roots of the tree and the grass) I just thought ofmy grampa. We used to lie out in the grass all the time when I was a kid and he would tellus stories. I dunno why it bothers me." The second drawing (Figure S1.2) depicted Sonya'ssister's children. Sonya talked about how alike she and her niece were. She explainedemphatically, "Well, she looks like her mom but she's got my hair and my temperamentand my tomboyness and independence. Don't touch me, I'll come to you. I've done that allmy 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 wistfullyabout the children's existence, "They got people there for them all the time and they are sowell brought up. They are taken care of and their teeth are taken care of and their healthis taken care of and they are loved and they are taught really wonderful values". Sonyalamented, "We never had anything, we were struggling all the time. We had second handthings. We made our own things. I still feel bad, I still feel like a victim. I still feel poorme a lot". Sonya explained the third drawing (Figure S1.3) was a picture of a travel fantasywhich she felt she would probably never realize.Sonya began the TST drawings whilst telling two stories: one of a woman whomSonya perceived to have been very cruel to her, the other of a woman who had thankedSonya 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 awildebeest, 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 amfunny. That's what I think". She then took a couple of minute to quite ruthlessly denigrateher appearance. In response to the second drawing (Figure S1.5) of what she saw when shelooked in the mirror, Sonya snorted, "Depends on what day it is". Then she muttered, "Fatface. 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."69As 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 ashalaylee 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 beautifulforest. It's a forest, but it's a magical place, it's not real. It's a green forest, part of it is butmost of it is crystal and glass. And the wizard stands by this tree. It's a willow. I alwayslike 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 mostbeautiful sound in the wind."We agreed to do some guided imagery to go to the wizard. Sonya found the wizardby a tree, on the right side of her chest. Then she determined that the wizard was actuallyoutside of her body. Sonya said she did not trust the wizard. She felt a tightness in herforehead. She felt she was supposed to surrender to him but she could not. She saidshakily, "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 alesson, or punished in that she wouldn't be loved if she were fat". She felt she needed to letgo of her vanity and her ego which would happen if she became fat. She began talkingabout the darkness on the inside. I asked her what it felt like to be fat on the inside andshe 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 fearedit was a trick. She was convinced that if she went near him, he would turn into somethingvery evil. She spoke with reverence, yearning, and distress, "It's a super wizard in all lightand I see him from all darkness. The forest is bright, but I am all dark. It's like everythingI want, he is. But I can't, I am too afraid to trust. I don't think I deserve it. I think I ambad. I think I am stupid. I am a failure. I am not successful at anything I do. I amunhappy. It is like why would he care?"70Sonya 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 herbrother everyday for years, "and I would wanna take my brother and just hug him and Ican't cause I feel I shoulda done something. The wizard tried to leave me then and Iwanted him to stay. So he did and he has never gone since. He's just anchored, justwaiting. Just waiting. I don't know what he is waiting for."Sonya reflected on her experience after we finished the exercise, "I am feelingsadness. 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 justwanna let go. I am tired of exercising, I am tired of compulsive eating, I am tired of spittingout my food.. .1 am tired of the whole process and my body just won't let go and I amexhausted from trying to and trying to turn it over. I am so tired of hating my body andgoing up and down and up and down. I am just exhausted and it just will not let go.. .toomuch fear."Therapist's log. session 1. Sonya vacillated between being very talkative and deadquiet. Sonya's voice was sometimes raw and guttural, sometimes breathy and girlish. Shesat slumped, and seemingly melted into her chair as though she wished it would swallowher 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 shegravitated very naturally, and quickly, to the guided imagery exercise. While in the midst ofit, she seemed to juxtapose very different images. The forest, for example, was both a placeof greenery, aliveness, and beautiful light. But it was also dark, and filled with crystal. Iwondered about Woodman's (1982) documentation of bulimics seeing themselves in glasscoffins, in view of, but sealed off from, life. The wizard was also confusing, he appeared tosymbolize both good and evil. He was good from far away, terrifying if approached. Andwhat was the connection between her grandfather and the wizard?71During 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 whileto take in all that was before her.Figure S1.1. "Poppa": Poppa was the name Sonya used for her grandfather whomshe associated with the Christmas tree depicted in the drawing. The Christmas tree, andthe roots, were largely red, not green. The drawing was filled with stars, black clouds, a redarrow, and a cluster of purple squiggles that resembled a penis.Figure S1.2. "My Kids": Sonya used bright colours and had drawn the both childrenwith open arms and smiles on their faces. She drew her niece with hands, and her nephewwithout 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 ared girl holding hands next to a purple (spiritual?) sail boat, all floating above the water. Inthe upper hand corner of the page, she drew a white cloud with a drop from the cloud inthe water below.Figure S1.4. "How the world sees me": Sonya drew the entire drawing using anorange/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 inpurple with a frowning face and a tear on her right cheek. She gave herself three chins, awide face and a very wide body below her waist. She did not draw fingers, feet, or agroundline.Figure S1.6. "My Inner Healer": Sonya depicted her wizard in the center of the pagewith a brown body that looked like a tree trunk firmed rooted into the ground. His beard,72face, and arms were rendered in blue. He held a large staff in his right hand. He had nofingers, or feet, but he did have ears and wore almost a frightening smile on his face. Hewas adorned with a conical, blue and green, hat. He stood beside a large willow tree drawnin brown and green.Session 2, November 6. Sonya brought a beeper from work and left it turned onduring the session. I did not comment. She began by talking about how she got alongbetter with men, or women who were like men. She talked about how she thought shedressed like a man but was, in fact, told by quite a feminine woman at work that she wasvery feminine. Sonya chuckled, "I was surprised. Cause they call me the biker chick atwork. Everybody calls me that. Cause I have a real toughness about me, a defense. And Iam 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'tknow. I think the femininity is my strength and my compassion for kids and people." Sonyastopped drawing and began crying saying she felt too much shame and pain arounddrawing. She talked about being terrified of getting in touch with what's inside. "Cause Iam afraid that is all there is. That all there is just pain and pain and more pain and that itwill take forever to heal it. Cause that's all I have ever felt and I am just sick and tired offeeling pain and sadness and wanting to die. I'd rather stay in denial so I don't have to gothrough this. It's not worth it anymore to me so that I don't have to be hurt. To feel likedying all the time. And then to hurt my friends because I am so fucked up because they areso scared for me. It's like I am not even a person. It's like...I just don't want to be hereanymore. This is all it has been. Is this. For years and years and years. Just a constantsadness. The constant depression. The anger. The fears the phobias. It's like I don't havea life. I have nothing. I don't believe that there is a power that cares about me or thatthere's a power that wants me well. It's like what I said about the wizard, I just can't73because if I go over it's all gonna be a big joke and it will be worse. It could stay forever. Icould lose my friends. I could get really, really fat. I could, lots of things. That's what Isee. I don't see happiness. I don't see good things. I don't think it's possible for someonelike 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 notnormal at all! Even my doctor said to me that I am a scientific phenomenon becauseeverything 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 goout with her; about how she would always end up alone because "there's nobody who canput up with me for long" because "I am not normal, I can't travel, I can't go in elevators, Iam crazy around food, I am angry all the time. Spiteful, miserable, depressed. Nobody... .1don't want anybody in my life."She talked about suicide, and not being afraid to die anymore, and that death wouldbe freedom. Sonya outlined methods by which she might kill herself, explaining that shehad been depressed since she was four. "I always felt I was weird and different and odd. Imean, at four I thought I was a failure and wanted to die." She talked about wanting to bea boy, "Oh, well. The way I look at it, men don't spend their LIVES, like I have, wanting tobe in a relationship. They get to do, they do things. They do stuff. They don't.., girls sitaround and wait for the fuckin' phone to ring to fall in love. Guys get to get out there andthey have adventure and do things. And most guys I know on their resumes they have allthese sports and all these activities they do. Women do nothing: reading, and writing andall this bullshit. Men do.. .everything", she sighed wistfully. "Men go out and dothings.. .there's adventure in their lives. There's power in what they do. Women sit aroundand wait for the phone to ring. Men are always in control. It's funny. I love women. I justlove women. I just find men more exciting and more fun. There's just so many more thingsthey do. I don't like men in general. When it comes to sex, I hate them. I HATE THEM.74Absolutely hate them. But with, men there's just so much.. .you are born a man, you areborn into power. We, as women, we have to be fucking secretaries, and bimbos and runaround with our tits hangin' out on TV to be appreciated. I see it in my business all thetime. Goofy guys can get great parts but the women have to be great lookin' or else theyare wenches or hags. It's constant. Constant!"We finished by talking about the movie, "The Wizard of Oz". Sonya loved it. Sheowned a copy of it on tape. She loved the message, "staying in your own backyard whichmeans 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 todie. We talked about loving ourselves. I set up a contract with her regarding her safetyover the weekend. She agreed not to try to kill herself.Therapist's log, session 2. Sonya had called the day before our scheduledappointment 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 hadsaid she could not make a rescheduled appointment on the 6th. By the end of theconversation she felt that she could.I continued to ponder the meaning of the wizard imagery. I was intrigued to hearthat "The Wizard of Oz" was Sonya's favorite film. I reflected on the possible parallelsbetween the movie plot wherein the wizard did not turn out to be what everyone thoughthim 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 butshe faltered and felt unable to continue because of the tremendous shame she felt whenshe attempted to draw.Telephone debriefing, week one. This week Sonya said she had discovered that shestill had a lot of anger toward people who had hurt her in her childhood and that anger iswrecking havoc in her adult life. She really wanted to get that anger out! Sonya was also75increasingly convinced that OA had not helped her. She wanted to feel like she haddirection in her life; she felt tired of feeling directionless. She talked about her discoverythis week of how much power she had given to men in an attempt to define her value; shewanted to change that.November 8th, Sonya phone call. Sonya phoned to say she could not make sessionas planned on Nov 9th so we rebooked for the 10th. She was crying hysterically becauseshe had seen her boyfriend, with whom she had broken up four days prior, two seats infront of her at an AA meeting "kissing and fondling a new woman". Sonya screamed, "if Ihad pills right now, I'd kill myself". To that end, we renegotiated our contract and sheagreed not to harm herself, at least not until we had seen each other again for anothersession.Session 3. November 10. Sonya arrived complaining bitterly about the cold and herjob. Even so, she appeared to be in a more elevated mood. We talked about thevulnerability 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 tosee the kids while she was in an upset state, "So I just have nowhere to go.. .1 am always theloser, always fucked up".Sonya talked about how disgusting and humiliating poverty was: "I grew up inpoverty. 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 sothat we could eat and it's disgusting. And it's where I am: poverty and no control. I amtired of feeling helpless and powerless."I observed that Sonya had been playing with a cross she was wearing around herneck when she talked about powerlessness. She said contemptuously, "don't know why Iwear it. I guess cause I wanna believe in God, but I don't. I think God hates me. I don'tthink God gives a shit if I live or die. I don't know what God is. If there is such a thing." I76attempted to clarify, "So even the higher power has abandoned you." She corrected me, "Idon't think the higher power has ever been there. Not for me. Once in a while things showup 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 lifewould be like if she could have whatever she wanted. Sonya began the imagery exerciseand smiled, "that I would be happy, I wouldn't want to be dead everyday.. .just not to hatemyself." Sonya paused and reported that she felt nothing but sadness. I asked her to gowith 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 stopstruggling. I encouraged her to stop struggling, to stop treading water. Sonya retorted thatnothing 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 letgo of control I will die because God doesn't care. If I let go of control I will eat until I blowup and I will be 300 pounds and I will be dead. I'll never be able to stop eating because Ican't. If I let go of food, God won't take care of me and I will die." We decided toevaporate the ocean. Sonya then visualized herself lying in the sun on a beach. Shereported that the wizard had appeared, that he had touched her hair, and suddenly she feltsix years old. I asked what the touch meant. She said "To tell me he knew.. .that I am tiredand I don't wanna do this. He knows I am just weary. He knows everything but he won'ttalk. He knows everything. He needs my trust. I am too scared.. ....all of asudden^ oohhhh, how weird.. .it's really bright, behind my eyes.. .it's really bright. Heknows I wanna let go but I am afraid. He knows everything.. .he is sort of like what I amlike with little kids".Interestingly, although the wizard was kind to the six year old, Sonya felt he did notlike the adult because she "was bad". She refused to reach out to his beckoning handbecause he would turn into "a scary creature with withered horns, like the devil". The77wizard was, in effect, two people: with the six year old he was "Jesus-like" in the light; withher 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 keptcalling Jesus all last night, and I hate that word... .it's too Christian for me". She was quitedizzy for a long time after finishing the exercise. I finally grabbed her hands and stood herup 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, shewas 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 atthe session. She elaborated, "I am really shut down today. I need to protect myself'. Wediscussed the comfort she found in shutting down. She talked about feeling very depressedand unhappy. I asked her about the conversation with Jesus the other night, what did shewant? 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 wannahave the courage to do it because I am tired. I don't see any hope. Nothing changes. I justkeep calling and calling like I have been doing for years. There is no God, I just don'tbelieve it anymore. Nothing listens."I remind her of the fleeting feelings of the presence of God that she had told meabout and asked what that was like when it occurred. She replied, "It's like aknowingness...it just sort of bursts through your whole body." I asked if her eating waseffected in any way when she felt these fleeting feelings. She replied that she almost alwaysate because she felt the "hollowness in an even more accentuated way" after she had felt aknowingness. After experiencing the sense of God, it was much worse in that she felt sheknew what she was missing. She bemoaned, "It's not life. I don't live. I just survive day to78day. I am alive. I am alive physically. Everything else is dead. Dead, dead, dead. I haveno spirit. I have nothing. Everything about me is dead.. .it's all dead. Everything inside isdead. 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 identifiedherself a four years old. I asked her to draw something from that frame of mind (FigureS4.1). As she drew she uncovered that she "never felt safe or cared for. I was alwaysunique. I was always the one at school who was the black sheep. People still look at me asa really unusual person. .1 always wanted to be like everyone else...never was.. .in society ifyou are different...artists that struggle and struggle, people that are so gifted are looked atlike freak shows." Sonya began to sob, "All I care about in my life is making sure thatpeople that feel different don't feel different. If that's all I could do in my life, that's what Iwant 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 thingslike that.. .1 really wanted them to go.. .people never pay attention to them. It's want shouldbe done.. .the way I look at the world. And then I got the disabled group to meet theBroadway show cast. The whole thing was worth it just to see that. And that is what makesme happy."Therapist's log, session 4. I felt Sonya's statements about being alive physically butdead in every other way were very powerful. I was struck by the beauty of Sonya's heartand her utter inability to recognize any of that beauty within herself. I wondered how thisrelated to her sense of Godlessness. Her only real joy appeared to come from helpingothers, from forgetting about herself and being truly altruistic.Figure S4.1. "Yellow": Sonya drew the entire image in a bright, lemon yellow. Itconsisted of a centered, thick horizontal line with another yellow line and a ball hoveringabove it.79Telephone debriefing, week two. Sonya reported continued binging. She also saidshe was not remembering the work we were doing in sessions. She still felt a strong urge tokill herself and felt that, "if God gave a shit, he would help me do it." Sonya lamented shewas getting fatter and yet could not find. She underscored how "terrified" of food she feltall the time.Session 5, November 16. Sonya arrived with a big mug of coffee. She was in a goodmood because she and her boyfriend, Jason, had gotten back together.I asked Sonya to draw happiness. She could not but agreed to a guided imageryexercise. She gravitated to her third eye (forehead area) and then dropping into a forest inher stomach which was comprised of a sea of Christmas trees. Sonya described the forestas pleasingly dark and cool, comfortable, quiet, and still "the trees are very peaceful andvery serene, they are content. There is something about trees, like a contented, happyperson... they give off so much. Just being, sort of like the wizard. I just like touching thetrees, they are like the wizard, they don't say anything, they don't say anything they justknow, 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 Iwill get well because I don't want to be disappointed anymore...I am afraid to say things areokay today because what if they aren't tomorrow. I don't trust it because it will be takenaway... everything will be taken away from me just like..." Sonya paused and began to cry, "Ihad a daddy...and he went away."Sonya regrouped herself and reported that she had reached out to touch one of thetrees. Suddenly, it began growing, "a Paul Bunyan tree.. .it's so big it's overwhelming.. .it'sgetting scary.. .it's getting mean. It's me, the tree is me!!! It's the grandiose performancetree. It's filled with lies, garbage, ego and fear, it's so huge because there is so much of itthere... .full of crap. It's definitely me. I don't trust it." I asked about the other trees in the80forest. Sonya described them as covered with jewels. I asked if Sonya could cut the bigtree down so that the other trees might receive more sunlight. As she contemplated thisidea, she suddenly announced that the wizard was standing right beside her, wanting tohelp her in her task, "He has an axe too. He is very very small, even compared to me. Heis radiating light. The tree is so evil. It feels so evil. And it is daring me to touch it. Veryevil. And it so big." Suddenly the tree became red. Then Sonya felt her grandfather waspresent. The tree was huge and solid inside. Sonya was not convinced the magic axe shehad would work. Then Sonya took pity on the tree. She felt that the tree was very sad. Shefound herself not wanting to hurt it or destroy it. She discovered she had respect and lovefor it at some level.I asked Sonya to put the axe down and to hug the tree, to pay attention to it, and togive it a kiss. I spoke, "I love you tree, I know you were abandoned, and left alone and noone was there for you. I feel your sadness and your loneliness. I understand why you arefilled with anger and meanness because no one paid attention to you. Well I am here tolove you."Sonya's voice cut through the room, "My God, it's shrinking.. .oh God oh God, mywhole body feels so weird". Sonya began to hyperventilate and her voice sounded panickyand incredulous, "It's like someone opens a valve and let all the air out of it...it shrank.. .nowthere's this little thing that died.. .1 feel so sorry.. .it's like I killed something". I assuredSonya, "No, you gave it lots of love.., as soon as it got the love, it was able to take on adifferent 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 topick 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 withSonya. Her mood fluctuations were also reflected in the extreme differences in good andevil in her imagery. Both the wizard and the tree were good and evil, they both had a81"knowingness", neither one spoke and yet had a strong consciousness about which she wasacutely aware. I was also interested that Sonya felt so much discomfort with white lightwhereas she felt fine with the blackness; it was home to her.Session 6, November 19. Sonya arrived, chewing gum, and announced immediatelythat she had broken up again with her boyfriend which had caused a "complete nervousbreakdown last night. Men don't respect me. Men look at me and I am just a fuck. It's alltied up in the body image thing, the looking good thing."Sonya began talking about how she was defending her illness, "I keep saying I havebeen working real hard for years. I am working hard at fighting everything that is comingmy way. I know I am wrong but I am not fucking going to tell you that. I have worked verywell at not getting well. I have tried hard to get well but I have not been willing to doanything that anybody says." I asked Sonya if she knew of any good things about not gettingwell. Without hesitation she responded, "It shows everybody that I am right. That I am theexception. It gets lots of attention." Sonya paused and then reflected some more, "I don'teven know if I wanna be well. It's too uncomfortable for me. It's too hard to stay happy. Iam so one way. I don't know if I'll ever be able to break out. It's too much work. I'd like todo 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'tfeel better. I might as well stay here. I fight everything." I enquired of Sonya as to whatshe 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 soshut down.. .1 heard a wonderful saying that pain is only resistance."I asked Sonya if she sensed there was anything beyond the resistance. She repliedquietly, "I don't know if there is anything else. I only know where the anger and frustrationis. I am so frustrated it's like there's this huge ego that won't let go. And I pray and I prayand 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."82Sonya draw a picture of her ego (Figure S6.1). As she drew she confided, "My ego isso 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. Ican'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. Itis 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 Iam lost. I have lost the war. It's like do you want to be right or do you want to be happy. Ihave to be right. That means somebody will have one up on me God...God will have oneup on me. If I let go of all my bullshit, anger, negativity rage...I lose my bitch. It is amazinghow many men want to be around me and I am a bitch to them. I have that power." Iasked Sonya if we could not talk with the bitch, empower the bitch? She sighed, "I thinkthe 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 itis...control. We are so outta control, we are going to control anything we can. Controlfood." I asked how she felt after purging. I think with my ego, I need to stay sick to feed myego. If I surrender then my ego loses.. .(to God).. .and then I have lost. If I lose, then I amlost" she stated emphatically, tearing running down her cheeks, "who am I if I am not thebitch. Who am I if I am not the slut? Who am I if I am not the mouthy... I don't know who Iam and I am too scared to let go...nobody would know me if I wasn't the tough, sleazy littlebitch. 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 andthat's it. There's nothing else inside of there.. .I'm a sick fucked up person.. so I have got torely on something, so if I don't get thin, I am nothing." I asked Sonya about the opposite ofsick and screwed up. She smiled, and said resolutely, "Joyous and free and peaceful". Butshe quickly snapped back to describing her relationship with, and seemingly talking to, her83ego, "hate, it has complete control over me. I am not going to let you have all the goodthings. 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 feelpositive. I eat something and try not to be afraid of this...but it says yes you are. You aregoing to get fat...you are going to get fat. And then I have to spit everything out. And ifyou get fat then you are not attractive therefore...you'll be alone, and afraid." I commentedto Sonya that her ego seemed to get her coming and going: if she was slim, she waspromiscuous 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 theego.. .it's the evil in me. It's the Satan.. .it's wants to kill me, it wants to keep me so unhappyso that the God part will not come through. It won't let go, it's afraid that if it does it willdie." I asked Sonya where the God part was in her body. She replied that it was in herheart. She began to draw her heart (Figure S6.1). She described the knowingness as beingin 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 heartto visit with the God. She was unable to do this. She drew an absolute blank. Wecompleted the exercise and I complimented her on her good defenses, taking care ofherself 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'son again, off again relationship with her boyfriend felt like an allegory for her own battle ofrelationship with self. She was the one breaking up and getting back together. Herboyfriend wanted to be there for her but she felt uncomfortable accepting her support andaffection, particularly since his care for her did not, as was usually the case with men,revolve around sex.84As we worked on the guided imagery work, I felt as though Sonya seemed aware ofher 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 representedanger, passion, sexuality? Her depiction of the black ego, was solid, and also pointing downto the right. It was very similar to the shape of a purple object she drew in one of thedrawings in the first session. I did not have any sense of the significance of the protrusionon the left side of the page.Telephone debriefing, week three. Sonya reported her binging had been as bad asever. She stated she did not want to come to therapy anymore. She had been pounding herthighs till they were badly bruised. She said she has been "begging God for surrender". Shefelt 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 felther 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 recoveredalcoholic who harbored no illusions about the difficulty of attempting to change one's wayof being in life. We began the session by discussing safety issues. After which time bothagreed to play in a role reversal exercise. I asked each to begin by assuming the posture ofthe other and taking a moment to "be" that other person. Jason began as Sonya by sayingthat he wanted to die, that the compulsion to eat was with him all the time, that he felt fatall the time, and chastising Sonya (as Jason) for still hanging around. He finished by statingthat 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 hewas at the moment. She volunteered kindly, "If you are this weight for today then that iswhat you are supposed to be. I care about you. Why are you trying to make me go away.85Why 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 whereyou are, you would rather fight it."Sonya stopped for a moment, and squirmed uncomfortably in her chair. Shecontinued, adopting a different tactic, "Can I get you to believe that what is going on inyour head is a lie.. .it's just a mechanical tool.. .and when the voice come back you can saythat... my dad told me I was nothing when I was growing up and I don't believe thatanymore.. .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 youmaybe see that if everyone else around you feels and sees something differently that maybewhat you are seeing isn't the truth." Jason finally responded by trying to divert Sonya'sattention asking if she would like anything to eat, to drink, or would she like to watch theWizard of Oz, or have her feet massaged? Sonya snorted and smiled recognizing her owntactics. We completed the exercise.Sonya reflected on her experience as Jason trying to reach out to Sonya. She statedthat it was very frustrating especially since she genuinely cared. Jason declared that he didnot feel willing to accept Sonya's efforts, "I had to defend my position. I would have to giveup. Then I would be out on a limb. I wouldn't know who to be. I have been this my wholelife. I don't really look beyond the fact that I am not willing to give it up. I am not evenlooking far enough to feel the fear. I am beginning to see that it is just a position I holdabout myself. Before that. I was who I was. You can't imagine how much energy it hastaken to defend this against the word. Jason's reaching out doesn't mean anything. It is justnoise...I have to defend who I am, it doesn't allow for it." Jason paused and attempted toread Sonya's expression. Sonya appeared deep in thought.Sonya continued with her experience as Jason, "It's not just frustration. It's feelingreally pushed away and cut off and really undone... .thankless. It's like trying to climb up a86sheer wall. You know what you are saying is right, and it would help. It's like a diabeticsaying, '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 energyput into than being angry. It's just a really open place than being shut down. It's muchmore open. There's just a lot of acceptance. There's no conditional terms. It was just a loteasier.. .1 wasn't so fearful. It's uncomfortable for me and so of course I shut down a lot ofwhat it felt like. It was a lot more powerful. Not in an ego powerful. Just to feel a lotmore 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. Shereplied immediately, "I am not comfortable saying I am well. I would rather say I amnot.. .it's much easier." I then asked Sonya if she had any questions for Jason regarding whatit felt like to be her for a few moments. Sonya asked Jason if he now understood, "the fearof not being able to get out of where she is.. the fear of being stuck...does it make sense howmuch I hate it but how much I hold onto it?" Jason mused that he was so determined to beright that he wasn't even feeling the feelings as much as he wanted to be right. Sonyaclarified, "So what I try to do is make other people wrong. And resist. I am always goingback to people and saying I am sorry. I hurt people." Jason volunteered, "I don't think youhurt people. You hurt yourself."I asked Jason how he felt to hear 'I'm sorry' all the time. But before he couldanswer, Sonya said, "It's a victim thing to do...disempowering. Like the wounded puppysyndrome. I always think I have done something wrong. I always have a sense that I am inthe way. I will inconvenience myself to the utmost before I will inconvenience otherpeople." I asked Jason if he would like to give Sonya a gift the next time she gets into aplace of being unable to accept love or support from anyone else. He smiled andresponded immediately, "a statue of her hugging herself". Sonya smiled knowingly.87Therapist's log, session 7. The role reversal proved to be very instructive. Jason wasan exceptional mirror of Sonya's behavior. She was stunned into seeing, and feeling, from adifferent perspective. She was given a safe method by which she could test out andexperience 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 herdark and her light, to allow her spirit to be born into recognition within her. This giftembodied that effort so elegantly. This session felt like a real turning point in Sonya'sability to move toward wellness.Session 8, November 26. Sonya arrived sparkly eyed and buoyant. She seemed adifferent person. We talked about the last session. I read to her what she had said whenshe was playing Jason. We talked about the experience of being in a place of comfortwithin one's self. We talked about the difference in energy required. Sonya went on todescribe how something had changed for her. She explained, "I am feeling so positive andnothing has changed. I still don't have a car, a job, I am still overweight. I hate my hair. Iam still eating too much. I feel very unattractive these days. I feel fat. I don't feel pretty atall. I want to get to the place that I am still binging over and still compulsing over. Yes, it'sa spiritual illness. There's a reason that I am still binging. I am still eating a lot and I can'tput things down and I am eating most of the time."Sonya began talking about acceptance; that that is the key to recovery. Sonya talkedabout surrendering her bulimia. She mused, "I do deprive myself constantly of food. I amfrightened of it. Terrified of it. There is no question it has complete power over me. I ampowerless because it has complete control over me all the time. I am always thinking abouthow to get away from it. What not to eat. Not what to eat but what not to eat." We talkedabout giving to oneself in other ways than just food. She talked about "buying bubble bathstuff.. .bathroom stuff, incense, loofa sponges.. .bathroom stuff, and CDs...that's what I buyfor myself".88Therapist'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 hadhad a near-death experience and now appreciated life in a different way. I wondered aboutthe interesting challenge for Sonya in how she would say goodbye to her old self and herold behavior. I was spellbound with how Sonya might continue to transform in light of herexperience 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 thoughtwas her being and move into her true, multi-coloured self?Telephone debriefing, week four. I phoned Sonya a few times but she was notavailable.Session 9, November 30. We started by talking about Sonya's money situation, hercontinuous feelings of poverty, and how she felt her bosses abused her desperationsituation by habitually underpaying her. Sonya also declared that her boyfriend, Jason, wasstarting 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 inthe kitchen because I can't stand the pain of rejection". She talked about a black demon inher solar plexus that made her eat. I asked her to draw the black demon (Figure S9.1). Asshe drew she said, "it's sort of satanic, from all different movies.. .it's so big, such a demonicevil, it just takes over my mind and my control".I asked Sonya if we could undertake a guided imagery exercise. She agreed butwarned she had never talked with it before. I asked her what protection she would need inorder to be able to go in and talk with the demon. She said she would need a white lightlike the wizard had. She explained the demon was like Gollum (a dangerous yet pitifulcharacter from J. R. Tollcien's, Lord of the Rings trilogy).As Sonya moved into the exercise she exclaimed, "something has clicked with thepowerlessness.. .1 feel completely powerless over the creature... the same way I feel about89the food.. .they are connected. I am just wondering if that creature isn't the food." Sonyahad focused her attention on her third eye. She stated, "there is an archway that is all whiteand then it is all black. I am not afraid of the darkness. I hate it but I feel sad for it. I wantit to stop but I don't know what it is. I have hated it so much. I feel like it is not a part ofme that is something else. It doesn't belong to me. It is another person inside of me. Ihaven't amalgamated with the blackness. It is another person controlling my life. I have tomerge with it and be with it and love it. But I hate the blackness, I hate the blackness somuch. It makes me eat. I know it does." Then she was hugging a big black ball. Shedetermined, "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 feelingthat talking to the blackness was like talking to a child, "the blackness is me when I amabout 5." Sonya felt really angry at the child and the child was mad at Sonya. Sonya feltthe child was making her eat for "safety and protection". Both Sonya and the child werequite diffident. Together they stomped and screamed for a while. Sonya paused to smileand said, "I am really glad she came!!!"Therapist's log, session 9. I interpreted Sonya's buoyancy surrounding herboyfriend's move with trepidation. I was not at all convinced that she would not plummetinto the emotional depths at any moment. All the same, her spirits were those of adifferent person compared to a week prior to our session with Jason. I felt that Sonya wasat a very delicate stage of transition from being in total darkness to allowing both dark andlight in her life. I felt almost afraid to move for fear of breaking the spell. I found myselfpondering her continual use of her third eye as a conduit, or clearing house for theemotions 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 right90with hook at end, a really long neck, and a black body with a white face with big pointyears. It was both amusing and somewhat sinister looking.Session 10, December 3. Sonya arrived still in a good mood. I marvelled at thechange. She talked about helping two OA people through providing them with support andpositive encouragement. We talked about her food consumption. Sonya admitted she wasstill binging but was spitting much less. She observed, "I don't really want to think aboutfood anymore. I want that to be the most unimportant part of my life because I want to livemy life now. I don't want that part of it anymore. I am so afraid of food still that I tend toeat very similar things every day. It's so boring. I don't want it anymore. But I still think ifI let go God is going to make me fat."We talked about the nature of personal transformations. We talked about havingpatience and not being in a big hurry. I asked about the wizard. She felt that he was still inthe forest. She speculated that he represented someone in her life, There is a big piecemissing that I haven't gotten yet and I am really aware of that.., the spiritual shit that has notconnected yet." I asked if it has to do with the wizard. She mused, "part of it does. There'sjust a feeling that the belief.. .it's just empty. I know there's a God. There's something but Idon't' know what it is but I keep asking for it. I haven't got that connection, there issomething not connecting. I still don't think it's God doing this. I still think sometimes it'sme. But I am not a higher power."We spent a good portion of the session discussing her concern over her agoraphobiaand how desperate she felt about overcoming that impasse in her ability to move throughthe world. She expressed a desire to visit some relatives out of town at Christmas andfretted over whether she could recover in time.Therapist's Log, Session 10. I was interested to see how quickly Sonya used anystrength she had found within herself to give over to helping others right away. Sheimmediately used her new found strength to help her fellow OA friends.91I was also intrigued that Sonya had moved so quickly into talking about heragoraphobia the moment things appeared even slightly better with her eating disorder. Itwas as though she needed to hang on to some major setback so that life would not appeartoo good and therefore be in danger of figuratively exploding in her face. This awarenessmay also lead to a potentially stronger therapeutic bond forged through the possibility ofthe bulimic client feeling a more profound sense of having been deeply heard andunderstood; embraced and appreciated rather than alone and alienated.Telephone debriefing, week five. In spite of several attempts, Sonya was notavailable.Session 11. December 7. Sonya brought me a present (some writing paper and awizard 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 midwaythrough and feel her emotions instead of blocking them out. She said she was able to staywith them. They were feelings of loneliness and abandonment caused, in part, by splittingwith Jason.Sonya also brought up an incident which had occurred on the weekend wherein shewas inappropriately approached sexually by a pseudo-relative. She had stood up forherself. Further, she had called him the next day and had really chewed him out. Sonyawas proud of herself that she had been very firm and strong and comfortable with herboundaries. She continued that she had had a wonderful day, "a day of answers coming tome as quickly as I asks the questions". We discussed the continued pressure she feltregarding getting over her agoraphobia before Christmas. I asked why she was putting allthis pressure on herself. She was not clear on that.Sonya then volunteered that she had moved the purple wizard from outside herselfinto her body. She said she had felt, "a high, bright light. Then it shifted...a rush throughme. But I know I am not there. It's changed a lot but I am not ready to pack my bags." We92talked about how much movement has happened in the last couple of weeks. She stated, "itfeels like a whole pile of rocks. And you move one rock and the rest tumble down. That'swhat the last two weeks have been like. It's like a clearing. The damn just burst and it ispouring out. So many transformations. But I have a real difficult time believing. That'swhat it is ...I don't trust.., travel. That is my life line dream. I have a hard time believingthat it could ever change because that is something I want more that anything. I think Iwould sacrifice my eating disorder... I'll keep that, just let me travel. I feel very powerlessover it. I want to rush this. I don't know if it's resentment. There's still something thatwon'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 theeye now, "I used to look at your feet." She stated that she did not feel she had "to win" withme. Then she began talking about her sister, about how jealous she was of her sister'snormalcy, success and relative ease with which her sister appeared to move through theworld. Sonya stated that she often binged when she went to her sister's house. She alwaysfelt 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, infact, 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 wasafraid she would never find "that kind of person who is so real. And I am so sick of beingalone. And I really trusted him. This is what I am really hurt about." Sonya also statedthat she was feeling abandoned by everyone else as well, which made her feel angry. Sonyaexplained none of her family members had asked her about her Christmas plans and evenstrangers had been awful to her of late.93We determined to do a guided imagery attempting to access her little girl. She wasunable to connect with her little girl but she was able to find some comfort in visualizingherself 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 describedwhat she saw when she looked at herself in the mirror (Figure S12.2) as still seeing "a lot ofpain and sadness. But my skin is glowing, "three people said that I was glowing and that Ilooked so different. My skin is better. I am taking care of my insides a lot better than Iever have. I don't get sick as much. I still feel fat but not as fat." As she drew her innerhealer (Figure S12.3) she said thoughtfully, "the blue is like the universe. And the yellow isthe yellow brick road, I've always said that was life is.. .already mapped out". I commentedthat 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'tknow. It's part of me. It's strength, power." Finally she added the dove. As we finished theTST we reflected on Sonya's progress throughout the sessions.Therapist's log, session 12. I suspected that Sonya was feeling abandonment issuesaround our sessions completing, not only around the breakup with Jason. To that end, shedid not even want to come to the final session. Since this was the last session, I felt the onlything 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 picturenot a body. Rather, Sonya drew five solid blocks of colour representing different aspects ofherself and four blue birds. The colours represented femininity (pink), outgoingness(yellow), prettiness (purple), intelligence (green), and powerfulness (blue). She felt thebirds symbolized her free spirit.94Figure S12.2. "What I see when I look in the mirror": Although Sonya had clearlydepicted an unhappy, crying person, I was delighted to see that she had used pinksuggesting 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 agroundline suggested an uncertainty about footing. I was not clear as to the absence of anose.Figure S12.3. "The Inner Healer": I was amazed by both the care with which Sonyadrew this picture and the amount of detail she included in it. The man wizard had turnedinto a girl (not yet woman) wizard. Her arms were outstretched in an open, andcomfortable way. She stood on a proper groundline. The wizard stood smiling at thebeginning 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 theattainment of a kind of peace. The birds suggested freedom and support. The willow treehad become a forest of evergreen trees.Telephone debriefing, week six. Sonya had become very suicidal again. I spent along time on the phone with her until I was sure that she would not do anything to harmherself. She promised to see her doctor and she had plans to continue in therapy withanother woman with whom she had already worked. I suggested to her that she seriouslyconsider anti-depressants.AlisonSession 1. November 2. Alison left her coat on for the first session. She said shewanted to feel protected. As she began drawing, she quipped that it reminded her of herchildhood. We talked about Alison's pre-school childhood which she remembered as beingidyllic, after which time she reported "there is nothing good to say." One of Alison's earliestmemories was of great disappointment and injustice wherein she missed out on receivingEaster eggs because the teacher had forgotten to put any aside for her. She also talked95about her parents never coming to see her win anything at sports day. She never felt herparents were proud of her. She felt all alone and very lonely. Alison felt she could neversecure her parents' attention. When she did try to attract their attention, things alwaysseemed to go wrong. She would end up being punished unfairly. She felt they neverprovided 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 weregetting older and weaker and she did not feel "allowed" to get angry at them for the way shehad been treated as a child. When Alison did see her parents as she had over the pastweekend, "little things will irritate me... so it was a really good weekend. But before theyleft my mom bought me a box of really nice chocolates."Alison completed the first drawing (Figure A1.1) and began to talk about what shesaw in it, "I don't know, when I look at that I feel confusion. I am in an unsettled placeright now. My parents have come and left. I have all these really deep loving feelings forthem and I still have a lot of resentment and every time they leave I get so screwed up for acouple of days." I asked if resentment and anger she had was not allowed to come out. Sheagreed that that was the case, "I can't do it in front of them. I still have a lot of fear. Andit's not fear of getting hurt now. But it is fear that.. .1 know my mom is trying the hardestshe has ever tried to have a relationship and she is real sweet and everything but it's.. .and Iknow that once I tell her not to do it with the food that it'll hurt her she doesn't know anyother way of doing this. She needed to leave something with me. I feel guilty if I don't eatthem (the chocolates), she spent money on them."Alison talked about her dad telling her over the past weekend to take abookkeeping course. She was hurt by this because it had nothing to do with who Alisonwas 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 Ilook, controlled the way I acted. Who I saw. I was very isolated. I was never allowed tohave friends because they didn't think Canadian children were good enough."96We 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 dosomething to jeopardize things. She worried that she overdid things, i.e., making way toomuch 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'slike I try to take control of everything but for some reason in the end it controls me morethan anything." She felt deprivation was a real issue for her. As Alison completed thesecond and third warm up drawings (Figures A1.2 and A1.3), she talked about heroverwhelming concern for the welfare of animals. She worried about how the wild bunniesin parks lived. She talked about making every moment special for her bird, Caesar. Shedid not worry about special moments for herself.When we started the TST, Alison felt she was unable to draw anything in responseto the first drawing (Figure A1.4), "How the world sees me". She explained, "I don't thinkthey see me, like I don't think I really matter. I try to think I do but I don't think anybodysees 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 themirror?", Alison started talking about some ugly jeans she owned. She felt compelled towear them anyway, "I've got this thing about you can't waste money. And yet I do. I wastemoney on, if I am really not feeling good about myself, I will go on a shoppingspree.. .clothes, records, it's kinda like trying to get everything I can to put my life back. If Ihave everything I can start with a just perfect...of course it never works out but...but I knowit now. If I see somebody else and say, 'boy they look nice'... I'll try to copy that. I am tryingto 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 saidthoughtfully, "it would probably be my seagull. I was always fascinated by seagulls.. .I'vealways 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 the97garbage piles and the whole bit and they go through so much hardship." I asked Alisonwhat she meant by hardship. She began to cry, "I get very emotional. I just get really upsetabout how people can not really see that any type of animal is just, they got feelings. And Idon't know how they live or how they feel or anything but they have their own lives and Idon't like the way people will walk over anything to get on with their own lives. And that'sa real hard issue for me. It has got its own life and it has got its own way and it's happy andit's not affecting us? So it's like how can people... .1 just don't understand how people can beso cruel. And I am not saying that I am a saint or anything. I can be cruel too and thewhole bit, I know that, but, it's a real touchy subject for me. I won't watch movies withanimals. For some reason, it's something that I hold."I asked Alison about animals in her childhood. She sighed, "Nothing was mine, theywere my parents, okay? The first animal I can remember was a dog. And the dogs werealways my dad's dogs. He had a shepherd, Suzie, real cute little thing." Alison stopped andbegan to wept, "And it got hit by a car...and he blamed me...the dog followed me across theroad. He beat me up for it. And then, um, like I've really tried to get over this but it's a bigissue.. .1 was, what, five years old. It was awful to watch the dog go through that. I think itdied 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'tknow 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 lovedher. She answered, "well, he never wanted me, to begin with. So I know that. And I thinkit was very hard for him. Like, he loved us.. .but he just didn't have time for us. We were anuisance in his getting ahead. And then he had another shepherd. And this one was one ofthose dogs that was just a dumb shepherd but he was so full of fun. And, urn, that was onedog they wanted to get rid of because he was a nuisance when they were building thehouse...the dog was constantly cutting his feet."98Alison finished the final TST drawing (Figure A1.6) and began talking about theseagull's freedom. She agreed to a guided imagery exercise. She discovered the seagull inher stomach and reported, "it's always cocking it head and listening to my responses! It's asif it is always waiting for me to say it's okay. Honestly, I think it is just sitting therelistening.. .waiting until I can say what I need to say. It's like there's a secret sentence or anallowance to give myself and I don't know what that allowance is, so I am not reallyprepared. It's like I have to go through something... "I think I need to let go.. .of the past. IKNOW I need to let go of that. I need to be more understanding. I don't know ifunderstanding but not to take all the cruelty that ever goes on on my own shoulders. I feeleverything, there's always such a black side to everything. I will look at the black sidebefore I look at the positive. And I know that I would like to look at the positive but it islike, so hard to remember to keep doing that."Alison talked about she felt things were so black and white; how she felt mostlyblack, and how she felt so responsible for animals. At the same time, she recognized thatthis responsibility was unreasonable. She felt she had to make some changes. The seagullsuggested she, "accept myself the way I am. Ummm. I can't change myself. I can't look atother people and constantly think how they see me. And, I've got to put my, it's like I see ablack part of me and I have been seeing a little bit of the light and that's really neat but onbad days, on bad days they are bad. I don't let the grey come it and I am really hoping tobe able to do that."We finished the exercise and Alison talked about how embarrassed she felt doingthe 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 wasfree and big. But it's ldnda neat to know that I have a deeper sense of this animal. It's awarm feeling." I asked her to reflect on the seagull until our next session.99Therapist's log, session 1.I was quite taken aback by Alison's overwhelming emotions around animals. Shewas 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 brightlycoloured, labyrinth-like circles interspersed with what looked like a black-faced smile, acage-like image, and several sets of water-like squiggles.Figure A1.2. "Isolation": The house was set in the middle of the page, away fromanything else in the picture. The frame of the house was yellow and barely visible. Thechimney, the door, the path, and the birds flying to the left of the house were all depicted nblack. 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 tothe right. Its body took up a large portion of the paper. Its stomach and tail were depictedin soft looking pinks.Figure A1.4. "How the world sees me": Alison left the page blank. She did notbelieve 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 takenspecial 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 themiddle of the page with no groundline. The bird was looking and leaning to the rightalmost expectantly, as though it was waiting for something.100Session 2, November 5. Alison took her jacket off for the first time today. Shebegan by talking about the discrepancy between Alcoholics Anonymous and OvereatersAnonymous 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 AAmeeting. I asked if the two programs were not based on the same thing? Alison agreedthat they were but her experience of them was definitely different. She elaborated, "Iwould say at AA I am a lot more open person. I can talk about it and I don't see the shamein 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 tomy 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 wasweird. It was like words were coming at me. 'Am I right or and I wrong?' It was like thishuge 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 oranything, so I am living with it. It's a first and it's uncomfortable." Usually, at the end ofthe fifth day, her pattern was to "take laxatives or I'd throw it up or I'd be exercising likemad."I asked Alison why she had decided not to purge this time. She was unclear, "I don'tknow, maybe I am taking responsibility for what I am doing. I am trying something. And Ifeel 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 notthat's what I am thinking about. I could be thinking about whatever I saw someone eatlast."101I asked Alison about the meaning of the chocolate her mother had given her lastweekend. She exclaimed, "that started me on my binge! That, that, that was it. That'swhen I started binging." Alison did eat some of her mother's chocolate, but not all of it, shedidn't want to eat all of it. Rather, she went to other chocolate sources. She felt it was away to kind of assert herself with her mom. Alison paused as she completed her drawing ofthe AA Alison and moved onto to drawing the face of the OA Alison (Figure A2.1). Shedescribed why she was drawing her OA face in a certain way, "cause I don't have anexpression on my face, I try to, but I know, deep inside, I am blank. I am an isolator. I liketo isolate. And my body is very fat. I guess, in a way what I do is I really know all mydefects. They go on and on and on."Alison observed that she liked to talk at AA meetings because she "did not feeljudged" - this experience was the opposite of her feelings at an OA meeting; she felt "emptyat those meetings. There's something I didn't get. First of all because I see myself as a sortof failure when I am going in there because I am not lifted." I wondered aloud whether oneof the reasons AA meetings may have felt easier for her was because, unlike her eatingdisorder, she had overcome her drinking issues. She agreed, "Yeah. And maybe it is easierbecause those urges aren't there. And I feel a lot more spiritually connected so I knowthere's that inner stuff. When I go to AA I come out knowing there is a God.. .there issomething taking care of me. I can feel it. It's a definite feeling that I get. It's likesomething hugging me. And when I am walking around there's something there." Iattempted to clarify what Alison meant, "from the outside in they are hugging you?" Alisonconfirmed, "yeah. If I'm really alone...yeah...I'd say from the outside it.. .and not from theinside I never thought of it that way. No, it's outside cause that's how I feel. I knowsomebody has wrapped their arms around me and it's okay, I've got protection. I don'tknow what God is."I asked Alison to clarify for me how the experience of drinking was different for herthan the experience of eating. She explained, "drinking took it all away. That took102everything away. I didn't have to deal with anything. The food really keeps you in it. Itmakes me more bitter. It's longer. It's just a longer form of punishment." I clarifiedfurther, "okay. So eating accentuates the feelings and it feels good in a twisted sort of waybecause you are getting the punishment you deserve." She nodded, "yeah, and I use food tobring my emotions out.. .my feelings. While I am purging that's when I start to feel sorry formyself. 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 Iget very angry. Very bitter. I can't say that I don't like chocolate but I have very negativefeelings toward chocolate. I don't enjoy it when I am eating it. But for some reason I wantto stay with the chocolate. And I know it brings.. .it doesn't bring back some memoriesspecifically with chocolate. I know when I was going to school, I was in elementary schooland my mom never had time to make lunch so she would always give me a dime to buy akit kat." Alison elaborated on how ashamed she felt in front of the other kids that achocolate bar was her lunch and that her mom had not made her anything. At the sametime she defended her mom explaining that she was busy, "but the chocolate still means alot and it's something that I know I have to keep away from because it just fuels me toomuch."We decided to do a guided imagery exercise in an attempt to talk with thechocolate. She discovered it in her stomach. "it's a forbidden, it's always kept away fromus.. .the chocolate. It was always kept away. I always had lots of questions and it's too bad Icouldn't..." She asked the chocolate why she could not have it and learned that it was a wayher 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 ifthey would give me something."Alison said she thought her mother told her to buy chocolate at lunch because hermother felt guilty. "I guess maybe that the chocolate was one of the first times where Irealized how much control my parents had. Like before, I didn't know. I was just told what103to do, shown what to wear, how to act, what to say and everything. But it was grade onewhere the chocolate first came and grade one was the first association that my parents keptme from other children. So I can relate with the chocolate being the first thing that theyused. It was the first thing that they used to get control of me."I observed that Alison sounded like she really resented the chocolate. Sheconcurred, "yeah. I mean I can't say that I don't like chocolate...but...I have a very difficulttime. I can never have a piece of chocolate and go that was very good, it's like there'salways stuff around it. Where I could have a piece of cake and feel great and then let it goand everything is fine. But I know the chocolate will just promote the binges and it'll keepit going." I queried, "the more chocolate you eat the more starved you feel?" Alisonnodded, "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 Ihad 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 internalfriend was not interested in chocolate, "because maybe what I don't do is talk to my buddywhen I am in the food. And so the buddy is what I talk to when I am okay. It's that gutfeeling maybe. Maybe it's my gut feelings that I talk to or basically me. But I know that itwouldn't want. I doesn't want the chocolate.. .cause I get too self-absorbed in me and whathas happened." Alison laughed and announced that she definitely did not feel likechocolate after our imagery exercise.The first thing Alison declared when she finished the exercise was that she wasworried she would forget what we had explored and learned. We talked briefly about herstrong need to be organized, write things down, and be perfect. But, she said, in anexasperated way, "I am so normal. I wish I could have excelled in something. Like somepeople were real perfectionist and they did fantastic in school. And I was just a normalstudent no matter how much I studied."104We began talking about the colour black. Alison said it was a colour she used towear all the time. She said now she wears bright colours but she still felt that the black wasin her face, "and I know that through school, I always had hair down and bangs and didn'twant anybody to see me. Even if I felt good I still didn't want people to see me. Now, If Iam backed away, and I don't look at anybody, nobody can see me. I don't think I make adent in anybody's mind. Unless I make contact with somebody. And look each other in theeye. 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 herfeel guilty that she could not express her feelings in front of them. I commented that I feltpart of her wanted to forgive her parents and part of her wanted to scream at them. Shemurmured, "yeah... there's that part of me that just hates them. I hate them. But I meanthey are old people. They are getting old and I know they did the best from what the couldhave done from what their childhood was like. And they had it tough... so I can see all thatbut 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 getthrough 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 gettwo good weeks of having a real normal life like normal people and then there will be thatfood stuff. Just hating myself and having absolutely no control. I mean, I manage to get upand go to work. I do that necessary stuff. I'll go to work. I'll pay the bills but everythingelse 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 (FigureA2.3). As she drew she focussed on her feelings, "I think the hate is getting smaller but it isstill there. And then I have a lot of compassion cause they are getting older and theirhealth isn't' good and my mom has to take care of my dad.. .1 feel a lot of compassion, Iwould do anything for them. If I had money and that I would just give it. So I have105compassion, hate, anger and guilt, I have love.. .it's not a warm love.. .like my cat I love mycat and I want to cuddle. The love I have for them is love at a distance...like it reallywouldn't bother me if I never saw them ever again but I need to know that are taken careof, 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 intogoing to the dentist." Alison protested, "I think I love them. I mean I really do I CAREabout them." She stopped and began to cry, "and it hurts to see them. Cause they aregetting older and I am angry because we will never be that, I will never have that family Ialways wanted and it doesn't matter what happens now, we are never going to have it. Soit's kinda like I go 'big deal' and I just don't wanna be a bitch. I don't wanna hurt them but Ireally wouldn't mind if I never saw them again and that hurts! And I don't think they wouldever really like who I was. They would always be disappointed no matter what. And I stilltry. I still try. But I can't do it."I asked Alison about how she felt she was different around her parents. She wentthrough a mental checklist, "I watch everything I say. I am really guarded. I dressdifferently. I make sure that everything I am wearing would be suitable. I try to makeeverything sound rosy." Alison then began talking about binging when she is tired afterputting 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 sojust take the day off. I can't permit myself to do that so when I binge. I can't have a normalday, I have to basically sort of relax and do nothing and eat. And I know that is one of thebig 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 gettingher 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 herOA and her AA experiences, particularly since the formats are supposed to be so similar.106For Alison, they were very different events. Her dearth of spirituality in the OA wassurprising.Alison popped her own bubble regarding the nature of her relationship with herparents and yet, clearly, a part of her did not want to explore this area. I was delighted thatshe had the courage to tell me that I had made her angry. I did not have the impressionthat being assertive came easily to her.Figure A2.1. "The AA and the OA Alison": Alison had portrayed her OA self ashappy 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 herface.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 definitefrown.Figure A2.3. "Feelings for Parents": Alison drew a grey stop sign. She broke thesign down into different feelings with extra heavy lines next to the words, hate, which wason the left, (mother?), and pity, which was on the right (father?)Telephone debriefing, week one. Alison felt a lot of material had emerged for herthat she had not contemplated before. Her thoughts were especially peaked around myspeculation about the connection between the use of binging to help literally bring upfeelings. With that new awareness, she felt she could now have a choice, "before I start abinge 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 thatpushed me back but further ahead too. I didn't know I felt this way. Now I am not going tohave expectations that we are supposed to be a perfect family. I will just accept it as what itis."107She also talked about having another vivid word dream after our second session. Itwas about, "a sentence from the 12-step program: principles before personalities". She saidthat it helped when she went on a shopping spree on the weekend. She stated that usuallyshe bought out of control, but, for some reason, the dream helped her to be stronger, tolisten 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 Iwere 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 shewas really feeling like binging, "I know these feelings so well"... "why am I at this edge tobegin with?" She was also feeling apathetic about even trying to avoid a binge. ^Webegan talking about her work environment. She felt that she worked with an "extremelydysfunctional man who was exactly like my father". Alison expressed great concern that shemight have to leave her job and actually go "into the adult world" to look for a job. Sheworried 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 somethingperfect and it wouldn't be right. And I know it's his stuff but...". She moved on tocomparing 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 afraidto approach him. It's like he has this shield, and I can sort of like touch it but I can't go toofar." Alison described the shield as a "YELLING". She chose to represent the yelling withthe colour purple because she felt it was "a frenzy".Alison began talking about the circle she often imagined around herself to protectherself from her parents. Alison also saw the circle as a way to protect her parents fromher. She talked about how she tried to show them that everything was wonderful. She108explained that she used to think about her father as a kind of "Yelling" as well, until shewas able to move out of the house when she was 19. Alison also talked about her motherand the great disappointment she felt in not being able to talk with her mother like a realfriend about real things.We talked some more about the man at work and I suggested we attempt a guidedimagery exercise to further understand her relationship with him. Alison expressed a greatdeal of concern around the fear of discovering something that might make her want toleave her job - a prospect she was not prepared to consider. However, she also did want togo ahead with the exercise, we proceeded under the condition that she was to speak up ifshe felt uncomfortable in the least. As we went inside, Alison's thoughts took her to the topof her stomach. I asked about her sense of the feelings that were swirling around in herstomach. She replied that she was feeling "frustrated because of yesterday" when Alisonhad developed a real craving for chocolate. She felt that the chocolate had to do with thefear she was feeling around the promise she had made to visit her parents next weekend, "Iam 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 wasafraid that her parents would simply not accept that. Part of her concerns revolved aroundthe feelings of wasted time in that "they don't talk about anything real". We took a momentto explore Alison's feelings of frustration. She perceived that part of the frustration was anobligation 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 likenow I know I won't go home and binge." Alison also took pains to explain to me that shewas "still keeping her food" In spite of her anxiety about her visit with her parents. She feltshe was still exercising a bit too obsessively however, she was not throwing up or takinglaxatives. Alison also expressed surprise that she actually "admitted" to me that she hadeaten some chocolate. I tried to underscore that I had no expectations of her behavior.109Alison stated that she appreciated practicing a conversation with her mother around howshe 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 firstweek. I was also aware that she had started to move into unfamiliar territory and I feltextra cautious about moving slowly and really ensuring that she felt safe. I was quitesurprised to hear about the striking similarities between the man whom Alison abhorred atwork and her father. I was also struck by the fact that she had worked in the same job, withthe same man, since she left her father's home, 13 years ago. She expressed what felt likean inordinate amount of fear around leaving her job. I wondered about any connectionsbetween unfinished business between Alison and her father. Why did Alison feel that shewould have to leave her job if she rethought her feelings about this certain fellowemployee?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 avulnerable way. She coloured the black cloud over several times. The purple shield felt asthough 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. Thebrown figure looked like a stick from the earth, undefined, androgynous. The green mayhave symbolized a kind of healing effort.Session 4, November 12. We began by discussing the phone call Alison had hadwith her mother, which we had rehearsed, regarding Alison visiting her parents on theweekend. Alison had held her ground with her mother but felt very guilty for doing so. Shehad had a strong desire to binge since the call. She had gone on a "controlled binge" buthad managed to avoid the trigger food, chocolate. Alison stated that she was thinking ofstopping exercising altogether for a while. I commented that this was a very black andwhite way of doing things. She sighed and said she wished she could "just let go". She felt110other 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'texercise'. Alison felt it was not a kind voice. It was malicious, savouring the fact that shewas being "lazy". As Alison spoke, she used her right hand (male) to discuss the presenceand then held up her left hand (female) to refer to a kinder presence that just let her besometimes.I asked Alison to draw the two sides (Figure A4.1). She drew some narrowrectangles on the right hand side of the page which she explained talked to her in a deepmale voice that was very authoritative and demanding like her father, "you wouldn't say noto this voice". On the left side, she drew undulating, pastel-coloured waves that weregentle, easy-going, listened to her inner self and would say not to exercise because she wassimply tired. Alison felt that the waves were genderless and felt like a breeze going overher body. She felt the male voice was like the devil...she felt as though these two parts ofher were "split like two people".I asked Alison about how the two sides worked when she talked with her mom. Shereported that she often felt like a little girl. I asked her to draw this (Figure A4.2). Alisondrew a 12 year old girl, "because that is when I started to want to have my own opinions andI couldn't." I asked how we might be able to raise the 12 year old into a woman so that thewoman could talk with her mother - would the seagull talk with us? Alison felt, for the firsttime ever, that he would. As we prepared for the guided imagery Alison announced thatthe seagull was flapping his feet because he was so excited and happy that we were going totalk with him. We moved inside and asked the seagull what Alison could do to encouragepositive communication in talking with her mom.111The 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 cometogether.5. To take care of yourself, meditate.Following the conversation with the seagull, Alison reported that the seagull wasvery 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 casestudies, appeared to have a sense of an internal dichotomy. She felt she was split into twopeople: one of them actually working actively against her best interests. I wondered howthis might effect her eating behavior or her sense of spirituality. I was equally struck by theclarity and detail of the suggestions from the seagull. The suggestions seemed to comefrom beyond Alison's conscious scope.Figure A4.1. "Male and Female": Alison drew the female energy on the left side ofthe page depicting it as gentle, fine, light waves of turquoise, mauve, and spring greendiagonally running the length of the paper. She drew the male energy on the upper righthand corner of the paper depicting it as dark black squares and heavily-pressed bluerectangles clustered together.Figure A4.2. "Twelve year old": Alison drew herself as a 12 year old who was justbeginning 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 floatin the center of the page.112Telephone 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 haddecided to start meditating. She had also determined not to exercise for a while until shefound 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 someboundaries for herself, everything did not feel so black and white.Session 5. November 16. We began by talking about how much Alison had changedover the past three weeks. Alison volunteered that she had been meditating daily for thepast four days and it had been very useful. She also stated she felt like binging today buthad not. She had had to put her bird of 14 years, Caesar, down. Her grandfather diedthree weeks ago and "there was no grieving and this was like, real grieving. Alison said thatshe was learning more about herself and accepting more about herself so she did not feelshe needed the "stability" of the bird as much.The desire to binge today had centered around chocolate, "I didn't want to deal withCaesar. I didn't want to deal with the feelings. I don't like people to see how hurt I canbe." The chocolate was supposed to keep her busy. Her mom used to give her chocolate tokeep her busy. She didn't binge on chocolate however, "I know where it leads me. And itdoesn'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 safeenough with her boyfriend to express herself.We moved on to talking about Alison's day visit with her parents, "it was realawkward and I could see her trying." However, Alison felt she had managed to hold herown. We talked about what Alison felt she had to forgo in moving toward a new kind ofrelationship with her mom. I asked Alison if there was anything to which she felt sheneeded to say goodbye. She cited two feelings: terror, and vertigo. I asked her to drawthose two feelings (Figure A5.1). She chose to represent the feeling of terror with an imageof a haunted castle with bats, "kinda like that feelings if I was going to watch a horror113movie and not quite certain I wanna see all of it". She depicted vertigo with several spiralcircles, "a lotta confusion. So at least I know that next time I see them, it won't bother me ifI turn around and say I don't wanna do that or that wasn't my plan.. .and yet I know that Iam not hurting them because it wasn't a big life plan". As soon as she completed thedrawing 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 amazedat the answers I am getting. And I didn't have to ask if it was the right thing to do. I knewit was the right thing to do. And it makes me relax. I used it to decide not to eatchocolate." Alison also stated that her eating, in general has been very good. I asked if theseagull ever entered into the meditation. Alison smiled, "he is always there and themeditation is water.. .1 am safe, I am really safe when I meditate". Alison also volunteeredthat she had stuck with a conscious decision not to exercise. "but I have to really work at itbecause I feel so guilty when I don't exercise. The only time I ever had guilt-free days waswhen I was fasting."We began talking about spirituality and binging. She stated that the two neverexisted together in the same moment. When Alison binged she just felt, "a big hole." Iasked her what she felt at the moment and she chose to draw a vine representing her senseof spirituality (Figure A5.2). In reference to the drawing she exclaimed, "it feels like it isgoing to come through and keep going. There is no limit. It is like an eternity sort of." Iasked where 'it' was coming from. She pointed to her lower belly. She explained that thatwas 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. ButI feel calm and safe, and I don't feel vulnerable! I know what I want. Sometimes that onelittle voice comes through like it's only for today. There's that little guy that is just waitingfor it to end. That part of me that doesn't want to believe." Alison studied the vine in thedrawing and said she knew that "there would always be new leaves coming along because Iknow I am going to be changing all the time.. .and that's a tough one because I like things to114stay the same. .1 used to always want to deal with everything at once and say, now that Ihave 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 awhite fish bowl. As she drew the figure she said she was concerned that the pesky littlevoice may be able to look up and find a way out. She determined to draw on a vacuumsealed 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 wouldbe shoulds. There's a big difference between shoulds and a choice. And now that I know Ihave a choice, it's not as threatening as it used to be. He's a lot smaller that I thought hewas. If the lid ever came off, he might crawl away, I could just put him back. It's not likehe 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 subjectnext time.Therapist's log, session 5. I was amazed at how quickly Alison appeared to bemoving. Each session she was discovering and incorporating more tools into her daily lifesuch that she could move away from bulimia. Alison seemed to be working especiallysuccessfully at feeling her emotions without having to binge as a result. Her determinationsto avoid exercise until it came from a healthier place; avoid chocolate; and to be tough, yetkind, in dealings with her mother, all required a tremendous amount of focus. She hadprogressed very quickly. I would have been more concerned at the speed with which shemoved 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 asplotchy grey and black castle with a little window on the lower left side. A huge tree-like115grey loomed on the right side. The castle was on the left-hand side of the page. The imageof vertigo was drawn in shades of okra, greens, and blues on the upper right side of thepage. The image felt tight and uncomfortable.Figure A5.2. "My Spirituality": Alison drew her spirituality as an okra, brown andgreen vine that moved vertically through the center of the page with no apparent beginningor 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 manifestedas a black stick man in white goldfish bowl with brown lid with handle. The man lookedlittle and weak; pitiful in his reaching up to the lid but nowhere near it. It looked like hewas falling back and asking for mercy but Alison would have nothing of it. She did not trustthis 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 meditationwas 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 bingesafforded her. She missed being able to eat whatever she wanted all at once, "in a way I amgrieving it.. .it's okay but it's still sad. Tuesday nights were a great binge night cause myboyfriend wasn't around. Now I have to think of what to do on a Tuesday night. I can't sitthere 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 (FigureA6.1). Alison observed that when she binged, she was isolated but if she was just homealone, she was not isolated, she is with the house, in the house. Isolation only reallyoccurred when she binged, "I cry a lot, I think about my lack of education (should ofs andcould 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 Ithink 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 above116thoughts when she was not binging. I asked Alison about the container in which she hadplaced all her items in the picture. She said it was a living room, "when I can see myself allI can see is me".Alison tried to remember what these different items meant to her when she wasbinging. She was puzzled, "it's really hard for me to remember that low feeling.. .what it waslike? Something has gone. It's a real desolation.. .like going in a real, hot, dusty desert andyou see the road and there is no end and you can't go anywhere else. Now I know that theroad goes somewhere and there are exits." Then it dawned on Alison, "I am missing thatself-pity. It gave me the reason to not turn around and do something. It wasnurturing.. .that's a good word. Like somebody hugging me."Alison looked at the picture she had drawn again and offered her thoughts on themoney symbol, "it makes me feel really bleak...I don't like it and I will get rid of it as fast asI can because I don't want to deal with it. I don't wanna be like my parents". Alison'sparents worried about money all the time. She appraised the drawing further, "I see apositive 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 amnot great, but I am more cautious, not being reckless. It just doesn't seem like such a bigdeal anymore". Alison laughed, "it feels like the binging was such a long time ago (8 daysearlier).. .and it was a forced binge.. .1 had to have a date I could remember...I wanted tomake a statement."We moved to talking about the issue she had raised at the end of the last sessionregarding her discomfort relating to her sexuality and her father. In fact, she felt not justembarrassed, 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 notwant 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 wasangry it came out in jolts". Alison then began to cry and said she did not want to talk about117this anymore. I waited quietly. She carried on, "he was angry, he was always angry, hedidn't want us and we just got in the way...now he has all the patience and all the time. Myparents shouldn't have had kids... mom wanted kids because she had a lousy marriage withhim...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 theother. When I was little I got a lot of nurturing but from the time I was six till I left it wasawful. First she wanted to control me and then when I was in high school, she saw me as athreat. It was a competition. She always wanted to compete. She would beat me indifferent ways. She would forget where her scissors were and accuse me. But I don't hatethem for it. I am lucky. I never went to the hospital. I don't have any broken bones. I amreally thankful."I asked Alison what she needed from the conversation. She reflected, "I wouldreally like to not have fear.. .1 have never talked about this. It's like I have this littledebate.. .it wasn't that bad." She told a story of neighbourhood kids telling her that her dadwas calling. Sometimes it was just as a joke but she would always run home and couldn'twait till she was hit and the waiting was over. Alison wept, "part of me feels guilty. Part ofme feels responsible." Alison wondered aloud, "how did I bring this on? I think about thiswhen I binge too." Alison talked about how, as a teenager, she had tried to portray that shehad had a great relationship with her dad.Therapist's log, session 6. I felt as though Alison was at a very delicate point in hertransformation in that she had given up the binge/purge cycle for the moment but wasfeeling a great deal of fear and trepidation about how to replace that experience. If she didnot find something that felt adequate, would she return to the comfort and solace ofbinging?I was struck by how torn Alison was with regard to feelings for her parents, even asshe talked about how violent her father had been, she sought to protect him and appearedvery concerned that I might think badly of him. Also, when Alison stated that her parents118should not have had children, I found myself thinking of the first TST drawing I had askedAlison 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 filledthe 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 peoplerepresented judgment; the house represented things that never were; the booksrepresented the education she never received. The drawing was a black box of regrets.Telephone debriefing, week three. Alison talked about having trouble knowing howto handle the extra time she had on her hands now that she was not binging. She wasthinking about binging but she was not doing it. She also found she had had some cryingspells. She was feeling very sad but did not really know why. She stated she was feeling alot of fear around no longer being bulimic.Session 7. November 23. We began by discussing the transformation that Alison feltshe was experiencing going from being bulimic to being normal. Alison declared, "I knowit's uncomfortable but it's not half as bad as the other". Alison reported she was stillmeditating and had begun to incorporate exercise back into her regime. We talked aboutthe empty space in her life that used to be filled up by binging..."I used to binge, I know thetimes when I do it, and there's a strange feeling around those times during the day when Imight have normally binged. I think I am just going to have to get used to it. I tend to justgo through it rather than trying to do anything."Alison told the story of a recent triumph. She was eating a bagel with a banana atlunch when a male co-worker asked her if she wanted to 'gain weight'. Alison declared, "itwould have been the perfect excuse to binge; no matter what I do it's wrong. At first I washurt but what it made me do was to turn around and say to myself, 'hey, I am not eatingmeat and butter' etc. So I thought, 'no I am doing well right now." I commented on herpositive boundary and asked her to draw that boundary (Figure A7.1). She began drawing119right away stating that, "it's got real solid walls but I had to really work at it. The yellow isme processing it. I made a list, his points and my points, and our points over lapped. I hadto 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 theweekend. 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 aroundcommunication with her parents. Alison mused that there was "a dimension" to get throughbecause she had things to say to her parents as they were, not as they are now. Weembarked upon a guided imagery conversation between Alison and her father. She toldhim that she was afraid of him when she was a child and that she felt he did not support heror teach her responsibility. Alison talked about she felt different from the other kids, "Ithurts 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 wouldhave been your education. I had no clue what the world was like, I was so complying andso scared. You didn't have to hit so hard. I didn't like the way you hit me. You disciplinedus in so much fear. Not to learn right from wrong but to make us fear everything. We werehumiliated. Everything we did we were humiliated. When I was 8 years old you had mewashing floors till 12 o'clock at night."Alison stated that she wanted her father to acknowledge what he had done so thatshe 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 alsovery cruel. Alison felt her mother "wanted to hurt, and to humiliate, she was angry that Iwas a girl.. .1 was something to keep pulling down and kicking... she felt that way aboutherself. I felt sick, I felt like crap".120Therapist's log, session 7. It felt as though Alison was in the midst of courageouslymoving from one world to another. She was bravely and consciously experiencing thetransformation from living her life outside her body to moving into it and claiming all thatwas hers. She appeared to be learning what it felt like to live inside of herself accepting allthe 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 tocommunicate with others quite comfortably.Session 8, November 26. Alison had not even sat down before she began talkingabout the anger she felt toward her parents which had emerged the day after last ourguided imagery exercise. Alison said her anger had lead to a "controlled binge.. .it's what Iused to do when I got this angry. I forced myself to have chocolate and then I said, 'no Ijust don't want it'. Which is really neat. What it was, was that I thought that theconversation I had with my mom and dad was crap. Number one, I am angry at them. I amreally, really angry. To be honest, I want them to have a wonderful life. That is true. But Idon't want to be included. I really would like to get on with the rest of my life with nothaving to deal with them. For me it's not hurting them, it's me getting on with my life. Ijust 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. Ididn't take any pills, I didn't throw up. I didn't exercise." Alison paused, took a deepbreath, and smiled. I asked Alison where she had felt the anger in her body. Alisonpointed 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 becauseshe found herself vicariously condoning their behavior toward her when she had been achild. Alison agreed and yet she felt she could still never do enough for them. She alwaysfelt, "I've got to do more, better." Alison paused and then began talking about how she121handled anger when she was a child, "it was like when I was little I used to have tantrums. Inever had 'em in front of anybody. And I would start pouring everything into the middle ofthe 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 ithurts. It's more sad. Two old people and I am not going to change my feelings towardthem no matter what. When the day comes that they are to go.. .1 feel, it's like a relief. Iwas trying to prove I was that perfect person who wanted everything to be nice and that'scrap. It's wouldn't bother me to never hear from them.. .and that feels so good! It just feelsso 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. Alisondiscovered that the seagull was frustrated. She reported that the seagull knew she wasscared about hurting her parents' feelings but that she needed to get on with her life. Theseagull suggested that to move forward Alison needed to "forget who I was. He get's angrywhen ever I turn around and say I don't want to hurt them. He gets really pissed offbecause it's like, you are not going to hurt them. I think there's a bit of ego there. As longas 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 rememberthe bird the next time she is in a difficult mood. "I feel a little more comforted knowingthat he is there than I do knowing that there is a God there. I have to work harder withGod. And with the bird, he is working with me. It's like he is there and I know that and nomatter what, if I go wrong, he'll be there. He's in my solar plexus and it seems like he isgetting bigger or he is fluffing out or something. It's like it protects me outside but the birdprotects me inside. And I think God is protecting me from the things outside of me...I willalways be taken care of at work and things like this. The bird is going to protect my122feelings. So if I am going to get really angry.. .maybe I can talk to the bird. I wonder if Icould meditate on that. It may be kind of neat 'cause then I could have a one to onecontact with it...emotionwise...learn what to do with my emotions. Anger, anger is hard forme to show, it's like I always have this great big huge smile on my face, to soften. And I getso 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 booksto learn more and grow. She said she wanted to read more about meditation because, "it'smaking 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 muchuncensored emotion. I felt as though I was watching a fever finally breaking. Alison hadstopped being "nice". She was very real, and passionate in her expression of her feelingsabout her parents. She felt alive!I was memorized by Alison's distinction between the internal, healing seagull and anexternal, protective God. What does this mean?Telephone debriefing, week four. Alison announced that she was starting to makevery strong boundaries. She felt the meditation was continuing to help her to open up andto relax. Alison determined that she did not want to go to OA anymore. She did plan tocontinue attending AA meetings because she was empowered by them. Alison felt that shewas learning to concentrate on her inner self now instead of concentrating on food. Shefelt that "food is a symptom, it is not the cause".Session 9, November 30. Alison began by saying she was feeling some self-pitytoday because her boyfriend was taking a course and paying her less attention. Sheobserved that she felt the emotion but she did not binge. Alison felt that feeling an123emotion 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 withthe energy to binge. She paused, "That's what I used to do. One thing would trigger meand 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 thesefeelings. Not to try to take control of them. To feel them and not to turn them around. Icould have made that pity into an anger."We began talking about a possible connection between Alison's sense of sexualityand food. I asked Alison how she felt when she was looked at by men. She frowned, "itwould 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 thetopic 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 hadto think about what she was going to wear when she saw her parents. We talked aboutdeveloping more protection for herself for when she visited her parents. Alison drew apicture 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 putmean or upsetting comments and send them back or away from her.We talked about her meditation in which she recently spoke with the seagull. Shesmiled, "we were like two really good friends just sitting and watching the stars at night. Sohe knew I was there. I felt warm, safe. When I start to think of the seagull more that'swhen 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 farbehind me. It is too close. I am afraid I could get sucked back into it."124Alison commented she had backed off the exercise again, and had to "work at notlooking at my outer self. I am having a little more trust. I know that what I am doing isfine. And, as the food goes, I will never be 200 pounds. There is a little bit of concern thatI 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 Alisonseemed to be progressing: being in her feelings, coping with daily hassles, and clearly seeingwhat her normal pattern would have been in the past, what her new pattern was, andresponding 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-handside of the page with a light blue screen (like water.. .the subconscious?). The envelope onthe upper left part of page was flesh coloured with a big black seal. The foreboding qualityof the seal almost suggested that the contents were poisonous.Session 10. December 3. Alison arrived in a good mood and immediately beganexpressing the difficulty of "dealing with life on it's terms and not having a crutch to dealwith it". Alison was finding when one little thing went wrong, it was easy to use that as anexcuse 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 eatinghealthy. There's no junk and no chocolate but I am used to living on a muffin and a bananaand a binge and getting rid of it. I am not used to eating normally. I need to get rid of thatoutside self-consciousness. I am going by common sense knowing right now my body isgoing through some changes. I am being easy on myself but I am going through all of thisturmoil. 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 peopleeat normal!?" We talked about the challenge of learning what to replace the unwantedeating behavior with. "I don't want to go back to that superhuman again. Because I willburn out. But it's just having the patience day by day." We talked about the fact that125Alison had made a decision, had some broad strokes in her mind of how to build her newway 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 withthe TRUST; that it would be okay; that her slight weight increase would not get worse andworse but, instead was just an acclimatization to a new way of being. She was havingtrouble learning how much she should eat for her size...has no sense of what is actuallyappropriate for her in a normal, healthy way. Alison was feeling really self-conscious ofherself right now... "if this is going to be it, will it be okay for me? Will I get to the pointthat I really like myself as I am and be able to get on with my day. I get up and my firstthought is, 'I can't wait until breakfast." I asked Alison about her meditation practice. Shewas continuing with that practice, "it is giving me the willingness to know about my defectsand resentment so that I can begin to change them."Alison began talking about another man with whom she worked who irritated herbecause he seemed to be allowed to get away with not doing "grungy" work that otherfemale staff had to do. Alison fumed, "He does bring out rage in me. And when I getangry I think about my parents. So he brings out the anger I have for my parents. It's thatunfairness." We decided to do a guided imagery with the seagull. Alison found him in hersolar plexus where he was resting with his back to her. She asked the seagull about how tocope 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 andappreciate the people she did like at the her office rather than focus her attention on thelazy man.Alison observed that she knew the seagull was there during the day but that she didnot really think about him. She expressed a desire to have him be in her thoughts moreoften. She asked the seagull to do this and he agreed. Alison finished the exercise. Wetook a moment to reflect on the potentially deeper nature of her irritation with the hermale co-worker. I suggested she may have been attracted to some aspect of what he126represented to her and could she perhaps draw that (Figure A10.1). She drew a picture ofthe 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, hedoes 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 askedeven though she might be disrupting her work to do so. We rehearsed a situation and shefelt pleased with her solution.Therapist's log, session 10. Alison appeared to be slowly acclimatizing to a moreforgiving and kind way of being in the world. She seemed to have recognized that she didnot want, or need, to be superhuman in order to justify her existence. I was struck by howincreasingly wise, and supportive the seagull was. I was also amazed by how effortlesslyAlison seemed to be able to access that information.Alison appeared to respond really well to the rehearsal we worked on regarding herdesire to be slightly more assertive as work. She was excited by the tools she discoveredshe had within herself.Figure A10.1. "Desirable Characteristic": Alison drew an orange balloon (creativeways 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 withthe imagery exercises we did during our sessions especially during her meditations. She feltthat she was starting to feel a "sense of power.. .that I do have choices... food is not an issuenow." She worried that she might lose humility and perspective now that she was doing sowell.127Session 11. December 7. Alison began by talking about a wedding she had attendedlast night. Usually she would have binged the day after a wedding. She did not binge thistime 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" ofherself. We talked about the rehearsal we had undertaken last session regarding Alisonasserting herself more at work. She reported that things had worked out well and that shehad felt pleased with herself about that too. We talked about her boundaries. She saidthat each morning when she meditated, she visualized a clear shield which helped toprotect her. I asked whether Alison was aware of the presence of the seagull during hermeditation. 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 aroundher. 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. Shesaid excitedly, "the seagull is flying forward.. .really independent. Is not watching me butknows 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 thatthe 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 reallyseen 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 isagreeing 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 canunderstand that he can explain but until I have the feelings for it, it wouldn't make anysense. Through the seagull I get the sense of comfort. So I talk to God, but at the sametime I am getting the contact from the seagull. I think the seagull is more apt to be willing128to discuss right from wrong and stuff but when I talk directly to a God, I am asking forwillingness and support; when I talk to the seagull, I am asking for comfort. I know as longas I keep doing this, I will get better understanding." I asked why the seagull was flying forthe first time today. Alison reported, "I think that he didn't need to be so, so close at thatmoment. I was doing fine. So he went to get some fresh air and I could rely on myself sohe 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 notsomething that could be "taken for granted". We talked further about the seagull andAlison commented that, in fact, the seagull had always been with her, even in herchildhood. She had used the seagull to take her away from her emotions. Alison reportedfeeling increased trust with the seagull.. "it was like knowing not to will things...they will justbe there. And also you have to work for and respect what you get out of it. It's arelationship. 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 theimage of the seagull to deal with the challenge of communicating comfortably with herparents. Alison did a drawing (Figure A11.1) of a pink outline of a seagull "just like asilhouette..and it would work to protect both in giving words and receiving them." Alisonalso mentioned that her boyfriend had noticed a big difference in her. Ile felt she wasmore independent, had a stronger sense of self, and had more opinions about what to do asa 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 wayanymore. 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 backtoo 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 the129end of each day. And I am sure I will get a little more vibrant when the body and myselfbecomes a little more accustomed to it. I sit there and go, 'this is so easy,' it's not, it's a lotof work.. .it's not easy, it's so natural."Therapist's log* session 11. I felt heartened by Alison's steady progress. She hadcome to sessions in an increasingly energized and positive mood. I was also fascinated byher connection between the bird and God. Fish, for example, have traditionally symbolizedChristianity. What was the meaning of the decoy ducks? Also, what did it mean that theseagull was finally flying, happily, freely? Had she attained a kind of spiritualindependence?Figure A11.1. "The Seagull": Alison saw the pink silhouette of the seagull as a kindof beautiful screen which could act as both protection and safety without impeding a caringcommunication. She was very happy with the image.Session 12. December 10. Alison began by declaring that life felt "more tiring" nowfor her than it was before our work together because before she used to be able to go into acocoon. Now she felt she had to face life head on. Alison clarified, "the compulsion is stillthere but it's different because before I had no choice."Alison related the story of a recent dinner engagement wherein she employed hernew found skills successfully. She did not respond as she would have a few weeks ago bybinging, instead, she kept her cool. She was delighted with herself. Alison explained, "itwas neat because I as I was driving I thought these are your opinions. Choices. And I knewI needed something that was comforting. Even I was shocking myself in the car at thatthinking.., that I could make these choices! Before I wouldn't even have to think about itcause there was no choice. Now I have done it. It's ldnda like being safe.. .like 'you did do itonce'."We talked about tools. Alison elaborated, "no matter what I say tomorrow I will getup and meditate. Before I do a binge I really do try to step back and go where am I. I130know there's that one tool of reaching out.. .that's a hard one for me. I am not that scaredof the future any more. I think it's because I do know that there's going to be tough daysand so it's ldnda like putting the good feelings into a bank account so that when the daycomes 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 stillhollow. It's coming strictly from me. So that's why that complaining of the past is just notgoing to do any good anymore. It's so neat, it's like I'm this mini counsellor here!!! Insteadof reading all those books, all that information is here. I see progress and I can see morecoming 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 seesme" (Figure Al2.1). Alison drew carefully and said, "It's funny because it's not only how itsees 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 Ijust saw a neighbourhood. And now I am seeing details. And I will quickly go back tosomething that pleased me when I saw it. It's not like, boy, you don't deserve that so don'tlook. And I see myself a lot lighter.. .1 don't see dark clouds around me. Even if I amdepressed. It's not black. It's a depression but it's not black. And the sea shows I am a lotcalmer. I am sitting, I am not moving. I am really relaxed. Nothing is perfect but it'slivable."Next, Alison drew a picture of "What I see when I look in the mirror" (FigureAl2.2). 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 amnot hiding. So it's okay, boy, I'd love to see lots of improvement but for today I am going tolive with what I have and have a good day."Finally, Alison drew a picture of "My Inner Healer" (Figure Al2.3). She declared, "Isee the bird moving around but there's this outline of fish.. .in the real distance. When Iimagine the fish.. .it's like seeing the bird here and there's a fish tank in front of it (the131brown is a symbol of that).. .1 don't believe in religion but I really believe in aspirituality...when I think about them and the way they spawn and the struggle. I really amoverwhelmed. They know where to go. That's one of the wonders of the world. No matterwhat they are going to go through it. You see where they are plowing against all theserocks trying to go upstream. Especially salmon.. .1 can't eat salmon. And this time he islooking 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'thate his colour. The blue says good, gentle...a colour that goes on forever and ever. Itdoesn't get darker or lighter and it's noticeable. He is content."Therapist's log, session 12. Alison's progress had been phenomenally fast. Isuspected a destructive phase would eventually follow. I hoped that she had amassedenough tools that she could move through it relatively quickly.Figure Al2.1. "How the World sees Me": Initially Alison had felt compelled toleave this blank. This time, she had drawn a picture that had filled the page with coloursand carefully rendered images: a tree, blue sky, a well-defined person perched oncomfortably on the crest of a wave. Alison showed herself in pink and purple clothingsuggesting a newborn spiritual awakening. The soles of her feet are together suggesting akind 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 showher 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 aseagull. But this time she used very different colours - blues, yellows, and pinks - and thistime the bird looked at the viewer very confidently. Also, Alison chose to symbolize thepresence of fish in the picture. What could this mean about her sense of an integrationwith God?132Telephone debriefing, week six. Alison reported feeling good but was being carefulto use "all the tools". She was feeling lonely inside but she was not binging. She said thedecision not to binge brought rewards when she woke up in the mornings. She said she wasgiving herself permission to be "reasonable.., to trust in her own instincts and to rememberto take care of herself."Follow-up ResultsCynthia. 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 sisterfrom whom she had been estranged. Further, she had taken a big step in overcoming herconcerns 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 atherapist whom I had recommended to her.Cynthia felt that the work we had done together was the "best thing" she had everdone. Cynthia cited her trust in the therapy as a crucial component in her success. Sheappreciated that I believed her, "I had a feeling you really understood what it was like to bebulimic. 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 Ihad an eating disorder."Cynthia felt during our work together she had learned a tremendous amount aboutherself. She explained, "it used to be that I didn't have any role models, I didn't haveanyone that I could work things out with, I felt powerless to change things. But with you, itwas so important that we spent the time to work things out. My understanding of peoplehas changed. I have a lot more tools because I have been heard, and believed. I have basicneeds like everyone else to be heard, and loved, and treated right, and given the space anddignity to recover from things and work things out."133With regard to the imagery component of our work Cynthia commented, "thedrawing 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 theonly way I could get the stuff out!" Cynthia giggled. She continued, "the imagery wasreally.. .1 use that all the time now. I really believe in that. I don't ask people's opinionanymore. I realized that I have the answers inside of me. I realize I just need to stop, bestill, and listen to it. I always have my little white light. That's where the answers lie. Ihave a lot more belief in myself. In some ways I have had to let go of my believes aboutpeople: that they knew more than I did and that they were better than me and they hadbetter answers to my problems. I know that's not true anymore. I don't look at people nowthat they are better than me." Cynthia said that she had no desire at all to binge or purgeanymore. She stated, "I'd rather cry, express emotion, than have to go into my room and besick. 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 oftreatment with him. She reported that the anti-depressants had, "taken the edge ofblackness 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 wasvery depressed after our sessions had ended and she had continued to binge and spit asmuch as ever. At the time of our follow-up session, although she was feeling good, she wasstill having problems controlling her eating to her satisfaction.Reflecting back on our sessions, Sonya felt that she had "really learned a lot" fromour work together. She felt that two main factors had contributed to her new insights: hertrust in our therapeutic bond, and the use of guided imagery. Like Cynthia, Sonya had notresponded strongly to the art therapy aspect of our sessions because she had felt atremendous amount of shame around what she deemed to be her poor drawing ability.134With regard to the issue of trust, Sonya explained that, "I couldn't rattle you. Yougave me a lot of room. You didn't run and you put up with my rages. For the first time Icould scream and yell and not be afraid of my anger. I felt it was a safe place to scream. Inever felt safe with my anger before." Sonya elaborated on what she felt she had learnedabout herself, "I learned I manipulate a lot. I learned about my fears - that what you feelabout yourself is not necessarily who you are. I saw how self-centered I was and I learned Ididn't have to take responsibility for everything. I now know that I am good person. I amnot 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: shewas happy with her eating behavior, and she was in a good frame of mind. However, shehad gone into a "rock bottom" tailspin after the Christmas holidays and it took her almost amonth 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. Duringthat 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 scaredto let anybody down. I was doing so well, so well, and all of a sudden I couldn't hold itanymore. Shame kept me in the binge. Now, I can't do it for anybody but myself, on myterms. Nothing has anything to do with other people." Interestingly, Alison felt that whenshe had binged, the quality of binging had been different. She felt she had not tried toisolate half as much as she would have in the past. She did not, for example, push herboyfriend away.In reflecting back on the work we did Alison explained, "it's like I have a littletextbook, and it shows me key things to do. But I did not want to open the textbook inJanuary. I felt fear because I was starting to get better and it scared me. I am so scared Iwill not be able to keep it up. I am scared of being a normal human being. I felt I wasgetting smaller, there wasn't just me in the picture, there were all kinds of things all of asudden. I lost control when I got better. It's being grown up. It's taking responsibility for135getting my life on the road and not having other people caretake for me. When I amhealthy, my boyfriend and others didn't have to wonder and worry about me. So it's hard toleave that world behind. If I got better I wouldn't be the center anymore. And the dayswould go so easy. The feelings would just pass. I keep my feelings with me and feel themwhen 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'sgoing through the fear of being an adult. When I binge I am a little kid in a real silent rageat my parents."V. COMPARATIVE ANALYSIS OF THE CASESTwo components comprised the descriptive framework developed to process andsynthesize the results of all three case studies: "Aspects of ways of construing andexperiencing" and "Patterns of Experience." Each of the thirteen aspects identified asalient 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 wascomprised of cycles of transformations which detailed a story of the healing journey of thebulimic experience.Aspects of Ways of Construing and ExperiencingFear of losing control leading to feelings of abandonment. All three womenexhibited an intense fear of losing control, i.e., of relationships, of levels of social supportfrom friends and family, and of being acknowledged, which they perceived would lead toboth being fat and, in turn, being abandoned. Cynthia was terrified, repulsed, andcryptically envious of fat people: "fat might be something that is contagious. And they areso out of control. And then I feel sorry for them because I think they must feel so awfulabout themselves. And it must be such a great shield to be that fat.. .it's a great way to keepthe world out."136Sonya felt food controlled her completely,. "I do deprive myself constantly of food. Iam frightened of it. Terrified of it. There is no question it has complete power over me. Iam always thinking about how to get away from it. Not what to eat but what not to eat. If Ilet go of control I will eat until I blow up and I will be 300 pounds and I will be dead. Myego loves to make me eat.. .it's like HA HA...everytime I feel positive. I eat something andtry not to be afraid of this...but it says 'yes you are. You are going to get fat.' And then Ihave to spit everything out. 'And if you get fat then you are not attractive therefore.. .you'llbe alone, and afraid."Alison sighed, "I do go out of control with my food. I can't control my food. I try tocontrol it. It's like I try to take control of everything, but for, some reason, in the end, itcontrols me more than anything... and when I binge, I isolate."The amount of body image distortion each woman experienced appeared tooscillate, depending on how she was feeling on a particular day. Sometimes, all threewomen felt they looked alright. Other times, Cynthia felt that her breasts were so big thatshe "needed to cut them off'; and both Sonya and Alison felt their bodies were "very, veryfat".The use of bulimia as a protective shield. All three women used bulimia as aprotective shield. Cynthia used binging "to hide from my feelings. If anything is onoverload I eat. It's like fuck you HA HA. You can't touch me now. But the only thing isthen I feel like an empty vessel having to fill myself up again because the only way I canprotect myself is with food. And without it in my body I am totally vulnerable. If I pukeand go work out, I am totally afraid... where if I have eaten and I don't throw up I feelashamed 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 wasthreatened in any way, which was often. She tenaciously fought the prospect of giving upher bulimic shield, "I keep saying I have been working real hard for years. I am working137hard at fighting everything that is coming my way. I know I am wrong but I am not fuckinggoing to tell you that. I have worked very well at not getting well. It shows everybody that Iam right. That I am the exception. It gets lots of attention. I don't even know if I wannabe well. It's too uncomfortable for me. It's too hard to stay happy. I don't know if I'll everbe 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 Ihad to grow up with cause I really didn't have real close friends." Bulimia provided Alisonwith a shield when she "didn't want to deal with the feelings. I don't like people to see howhurt I can be." Finally, it provided Alison with protection from the guilty feelings of notdoing anything, "I know binging just makes me not do anything. Like it is hard for me toturn around and say, I am really tired, mentally, or physically so just take the day off. Ican't permit myself to do that so I binge. I can't have a normal day, I have to basically sortof relax and do nothing and eat."Interestingly, although they expressed an abhorrence of their bulimia, all threesuggested this way of being was, in some ways, the only comfort they knew. And theprospects of losing the 'protection' of bulimia were, seemingly, unfathomable. Sonya wasconvinced that, in order to heal her bulimia, she would have to adopt a different kind ofshield and become very fat. Alison felt she would become unbearably inconsequential, "Iam scared of being a normal human being. I felt I was getting smaller, there wasn't just mein the picture, there were all kinds of things all of a sudden. I lost control when I gotbetter. It's being grown up. It's taking responsibility for getting my life on the road and nothaving other people caretake for me." Cynthia felt that she "had to be small was so that Iwould not be completely alone"; to cast off the shield of bulimia was to risk becoming fatleading to a dreaded loneliness.138A desire to purify. All three women exhibited a desire to purify themselves offeelings of dirtiness, contamination through somehow being able to start anew. Cynthia feltmortified with the prospect of how she felt she was perceived, "I always think it's written allover my face.. .like all the awful things. And I always think I am really dirty and bad. I feelso dirty." She wrestled with the dirtiness she felt from memories of inappropriate sex, "Ifeel like I am contaminated. I am contaminated by their sperm, their bodies. Theycontaminate the air. They contaminate me everywhere I go. They look at me walkingdown the street I am contaminated. They ruin me." Sonya "hated" the contaminatedfeelings she felt when men looked at her in hungry, sexual way and yet she was devastatedwhen they did not. Sonya and Cynthia's feelings may have been confounded by their sexualabuse experiences. I asked Alison how she felt when she was looked at by men. Shefrowned, "it would make me feel like I loathed myself. Like I need to hide me. Everythingabout me." Alison's feelings may have been confounded in that her first experience of aman was her father who abused her both psychologically and physically.All three women viewed the act of purging as a kind of internal scouring. Cynthiapurged to cleanse herself of distasteful contamination and emotions. Sonya felt she wantedto 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 feltshe needed to purge to cleanse herself of, and to express, stuck emotions. She alsoattempted to purify and start anew by going shopping, "I will go on a shoppingspree.. .clothes, records, it's ldnda like trying to get everything I can to put my life back. If Ihave 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 andfood-specific shame and guilt. All of the women felt global shame and guilt around theireating disorder and the resulting state of their "fat" bodies. Alison summarized all thewomen's feelings around food-specific shame and guilt when she said, "there's a lot ofshame there over the food and the abuse of what I have done to my body." They all felt139global shame and guilt around expressing emotions that may hurt, or have hurt others.Cynthia was quite tearful around feeling guilty for having "embarrassed" her schoolcounsellor in front of other students. She lamented, "I feel so ashamed." Cynthia also feltbadly about taking care of herself. She did not feel she had a right to do so, "I didsomething for myself and it depresses me. There's a lot of guilt attached." Sonya felt atremendous amount of shame around expressing herself through drawing to the point thatshe cried and was unable to continue. Alison felt enormous guilt around expressing hertrue 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 ofgetting hurt now. But it is fear that.. .1 know my mom is trying the hardest she has ever triedto have a relationship and she is real sweet and everything but it's.. .and I know that once Itell her not to do it with the food that it'll hurt her she doesn't know any other way of doingthis. She needed to leave something with me. I feel guilty if I don't eat them (thechocolates). She spent money on them."Cynthia and Sonya also felt shame and guilt around their families. Cynthia feltsomehow responsible therefore shameful and guilty around her childhood sexual abuseissues, "I always think it's written all over my face...like all the awful things." Sonya feltincredible guilt around not having somehow helped her brother when her grandfather beathim, "I feel I shoulda done something." She felt deep shame around feeling like a lesserperson than her sister, "she was perfect and I was a jerk. I felt ashamed."A sense of Godlessness. Throughout the course of treatment, each womanspontaneously referred to feelings of an inaccessible, hollow blackness within, and feelingsof Godlessness. Of the blackness Cynthia stated, "sometimes I look in the mirror and Itotally 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 amso attracted to it instantly. Everything inside of me is black. Everything is buried. It's allblack, just hollow black. I can't hear...whenever. ^I go inside, I can see the forest, but it's all140blackness... my head, stomach, heart.. .1 can only see emptiness and blackness. I don't feelthings, I think them. It is almost impossible for me to feel anything." Sonya felt theblackness spoke of loneliness and abandonment. Alison said, "there's always such a blackside to everything. I will look at the black side before I look at the positive. And I knowthat I would like to look at the positive but it is like, so hard to remember to keep doingthat."All three women noted they loved to wear the colour black. And all three womenappeared 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 apart of me that is something else. It doesn't belong to me. It is another person inside ofme. I haven't amalgamated with the blackness. It is another person controlling my life. Ihave to merge with it and be with it and love it. But I hate the blackness, I hate theblackness 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 Ijust said, 'God, you are the only one that can help me. This is something spiritual.' This islike a lack, right. There's no person. I am not asleep anymore it's like I can't explain thisrationally because it isn't." During a guided imagery exercise Cynthia stated that her senseof spirit felt "like a breath. Like an uncontrollable thing. It wells up and wells up and itcomes out and then I feel better for a couple of minutes and then it comes again. And Ijust feel so sorry for myself all the time. I am so sad. And I am all alone", she wept. Shepaused 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. Iam alive physically. Everything else is dead. Dead, dead, dead. I have no spirit. I havenothing. Everything about me is dead.. .it's all dead. Everything inside is dead. I have no141hope. I have nothing. I have no hope. I am too tired of trying to find it. I don't believethat 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 withGod, bargain with God, "It's like if I give up my ego I am lost. I have lost the war. It's likedo you want to be right or do you want to be happy? I have to be right. That meanssomebody will have one up on me. God... God will have one up on me. If I let go of controlI will die because God doesn't care. I'll never be able to stop eating because I can't. If I letgo 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 thesatan...it's wants to kill me, it wants to keep me so unhappy so that the God part will notcome 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 verymuch felt some kind of presence. She most clearly articulated this dichotomy when shespoke about how different she felt coming out of Alcoholics Anonymous meetings asopposed to emerging from Overeaters Anonymous meetings. When she came out of anOA meeting, she felt hollow, empty, depressed. "When I go to AA I come out knowingthere is a God.. .there is something taking care of me. I can feel it. It's a definite feelingthat I get. It's like something hugging me." For Alison, the concepts of spirituality andbinging never existed together in the same moment. When Alison binged she just felt, "abig hole." When she felt spirituality she felt like, "there is no limit. It is like an eternity sortof."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 butthat they are made of the same thing. She determined the light was closer, and was a paleblue colour. Sonya saw the wizard and God as different entities and yet they bothpossessed 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 of142me.. .1 will always be taken care of at work and things like this. The bird is going to protectmy feelings."Self-doubt. None of the women in this study trusted their own perceptions of theirworlds: their bodies, their judgment, their foundation. Cynthia flatly stated that, "I don'treally use a mirror that much. I don't always trust what I am seeing. I know that sometimeswhat I think I see isn't really what's real because I have become distorted in my views." Shefelt that she was, "kind of fake. I feel like I am not real." Sonya did not even trust her ownimagery let alone trusting reality. She was both drawn to, but extremely distrustful of thewizard. Similarly, with the Paul Bunyan tree exercise she exclaimed, "It's me, the tree isme!!! It's the grandiose performance tree. It's filled with lies, garbage, ego and fear, it's sohuge 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 toacknowledge her existence in the eyes of others. At the outset of treatment, when Alisonwas asked to draw her perception of how the world saw her, she left the paper blank. Shedeclared "I don't think they see me, like I don't think I really matter. I try to think I do but Idon't think anybody sees me so I don't see anybody really seeing me." Cynthia summarizedthe sentiments of all three women succinctly, "I am never believing myself. Because I amnever on my side and I am always looking for THEM to validate me. I am relying on whatthey 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 fromothers in an outcast sort of way: they felt like they were freaks. Cynthia proclaimed, "I amthe one who is a freak. That's how I feel. Everyone else is over there and I am totallyalone. I honestly feel like that.. .it's awful." Sonya felt she had medical proof to back up herbeliefs: "I am not normal at all! Even my doctor said to me that I am a scientificphenomenon because everything I get is either backwards or weird or symptoms that noone has even had before. I feel like a freak anyway. So that just fits." Alison felt she couldtemporarily masquerade as a normal person but, in fact, she felt anything but normal, "I143can maybe get two good weeks of having a real normal life like normal people and thenthere will be that food stuff. Just hating myself and having absolutely no control. I mean, Imanage to get up and go to work. I do that necessary stuff. I'll go to work. I'll pay the billsbut everything else is screwed up."Opposing attitudes/desires on a single issue. Each of the women exhibited anextreme 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 beingbulimic: each professed an intense hatred of most, or at least certain men, and yet each wasashamed of, or frustrated with, being a woman; they all saw bulimia as horrifying and yetthe prospect of getting well was, in some ways, terrifying.Minor individual issues also provided tormenting conundrums for each of thewomen. Cynthia desperately wanted to fit in with her peers and yet, "when I am fitting in, Idon't want to be there, I want to break out. And then I can't get accepted." Sonya felt adeep desire to move nearer to the wizard, but when she contemplated movement, goodturned 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 parentsbut she hated them; she wanted to do "good things" like exercise but she felt she had asmall devil-like voice in her trying to make her do "bad things" like eat. She described theexperience as feeling "split like two people".Self-pity. Self-pity was manifested by all three women in a direct form throughoutright declaration of self pity and in more vicarious forms such as feelingunacknowledged, 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 likethe inability to assert myself in a way that will best suit me and bring out the best in me. Iwanted to feel heard. I just wanted to feel acknowledged." And yet, she also felt extremelythreatened when her self pity might be taken away from her through some real144acknowledgement, "It makes me really angry when people acknowledge me." Cynthia oftencried and laughed at herself simultaneously declaring, "Total self-pity!!"And yet, Cynthia felt the "total self pity" she personified was a fait accompli becauseof 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. Theyprobably would have fucked me up but they wouldn't have touched me. They wouldn'thave used me."Sonya fought a similar battle, "I still feel like a victim. I still feel poor me a lot. Ialways play the victim, the hurt little puppy. The hurt girl." Sonya felt the prospect ofacknowledgement from others, true acceptance, was beyond the realm of possibilities soshe took offensive action, "I act defensive anyway so that I don't have to be hurt, so that Iam already hurt, already rejected so I can't be rejected."For Alison, being "normal" was a form of rejection. She had always wanted to excelat something in school, and to be acknowledged for her excellence, but felt she never haddone so. Alison felt that she dare not express her truth self, "I don't think they would everreally like who I was. They would always be disappointed no matter what. And I still try. Istill try. But I can't do it." Alison wanted both her parents to acknowledge how they hadphysically and psychologically hurt her when she was a child. But she felt she would neverbe acknowledged for either the pain she had suffered or for who she was in the world, nomatter what. So she used food to create a kind of acceptance, to alleviate the feelings ofself pity for brief reprieve, "I use food to bring my emotions out...my feelings. While I ampurging that's when I start to feel sorry for myself. But when I am eating, it's like I amfeeling that fire." The comfort of self pity was deeply ingrained in Alison, during herrecovery she noted somewhat longingly, "I am missing that self-pity. It gave me the reasonto not turn around and do something. It was nurturing.., that's a good word. Like somebodyhugging me."145Disenchantment with the perceived female role. Gender issues were a prominentunit of meaning among the three women. Volatile emotions around perceived femalestereotypes, restricted opportunities for women, and concern over parental preferences formales were explicitly and implicitly expressed through the sessions. Cynthia statedresolutely, "I believe every woman has to like get out of the mold. Get out of what I havebeen taught. I don't have to wear dresses. I don't have to look this way. I don't have to actthis way. I don't have to stick my fingers down my throat to express myself." She activelyloathed women's lot in the world, "the minute they found out, that's a girl, I am owned. Aboy is a man of his own, but a woman has to be owned by somebody. I NEVER wantedthat."On many levels, Sonya wanted to be a man. She was pleased that "they call me thebiker chick at work. Everybody calls me that. Cause I have a real toughness about me, adefense. And I am tough and smart. And I love male things." Sonya felt that to be a manwas 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 outthere and they have adventure and do things. You are born a man, you are born intopower."Alison's confusion and fury over gender issues was less overt than was Cynthia's andSonya's but it was as strong. She felt that her parents did not want her at all, but that thingsmight have been better for her if she had been born a boy. She was extremely frustratedover the stereotyping which she perceived to be going on at her work wherein her bossalways 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 ofherself 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 hairwas shoulder length) revealing a distinct denial of her female physical qualities.146Although each of the women openly professed, or alluded to a desire to be male atsome level, they also expressed contempt, and hate for men. Cynthia snorted, "I could livein the world very easily without men. They are useless. It's hard for me not to be angrywith men when I see what goes on in the world. And it's hard for me not to be angry whenI know what happened to me. I feel repulsed by men. The look of them, the touch ofthem, 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 acerbicemotions to specific males with whom she associated: her father, and two men with whomshe worked.Exceptional concern for the perceived down-trodden. During the course oftreatment, each woman exhibited exceptional concern for those whom they perceived to bedown-trodden. Cynthia was deeply moved by the plight of the transvestites. She wanted tohelp 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 inthe world. To me, I see something in them. They will sacrifice opinion so they can feel likewomen. They are spit on and shunned, it AMAZES me!" Sonya wept and smiled as shetalked about the joy she felt in helping the disabled group. She exclaimed, "all I care aboutin my life is making sure that people that feel different don't feel different. If that's all Icould do in my life, that's what I want to do. I just don't want people who are different tofeel bad about it." Alison felt a deep compassion for animals and exuded an overwhelmingconcern 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 pointof 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 ofanimal is just, they got feelings. And I don't know how they live or how they feel oranything but they have their own lives and I don't like the way people will walk overanything to get on with their own lives. And that's a real hard issue for me. It has got its147own life and it has got its own way and it's happy and it's not affecting us? So it's like howcan people... .1 just don't understand how people can be so cruel."The memory of an unsafe childhood. Each of the women expressed memories ofunsafe childhoods. Cynthia remembered being sexually abused by both her parents from avery young age. She lived her childhood on tenterhooks, "I could never depend on anythingor anyone. I was always wondering what was going to happen next. I was always scared todeath that I was going to say the wrong thing or do the wrong thing or be the wrong personso when I could get away with something I would completely just go for it because I knewthat I was going to get it anyway." Sonya also remembered being sexually abused by afamily member. She remembered watching her brother being severely beaten. Sheremembered constant poverty; never feeling like there was enough to go around. She saidshe "never felt safe or cared for." Alison spoke tentatively, and haltingly about how herparents abused her psychologically and physically; how they hit and kicked her, "but I waslucky. I never broke a bone or nothin'. I was never bad enough that I had to go to thehospital".Another aspect of childhood memories appeared to be distant and ambivalentrelationships with siblings. Each of the women appeared to love, hate, and simply not careabout their siblings. Cynthia sighed, "when I think of my sister.. .it's mostly just sad, justsad... 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 wasa tattle-tail." Sonya stated that she often binged when she went to her sister's house. Shealways felt that "she was perfect and I was a jerk. I felt ashamed." Over more than 14hours conversation with Alison, she only spoke of her brother fleetingly three times. Eachtime 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 vowingvehemently, "if it's the last thing I do I am going to suck those fuckers dry. But I couldn't148throw 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 paradeof her mother's boyfriends, and husbands, which she endured during her childhood. Froman adult's perspective, she felt compassion for her mother's difficult plight. From herchildhood perspective, she felt neglected. She spoke dreamily, and almost enviously of theproper upbringing to which she felt her niece and nephew were now privy. Alison wrestledwith 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 theycould have done from what their childhood was like. When I see them, it's ldnda like I amlooking at someone who doesn't have any face. And it hurts."Fear of intimacy. All three women feared the prospect of emotional intimacy. ForCynthia, "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 elsecare about me. So I don't really have any experience with people caring about me. After Ileft home, I never allowed anyone to care about me. If somebody was showing caring, Ididn't like them anymore." Sonya virtually chanted a mantra of sorts that she would alwaysend up alone because "there's nobody who can put up with me for long. I am not normal, Ican'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 amafraid that all there is just pain and pain and more pain and that it will take forever to healit. Cause that's all I have ever felt and I am just sick and tired of feeling pain and sadnessand wanting to die. I'd rather stay in denial so I don't have to go through this. It's notworth 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 realchallenge in expressing intimacy, "It's like banging on a door. Let me out. Let me out ofhere. And all you have to do is open the door...let me out of here. Alison felt she was149never able to have close friends when she was a child because of her parents' issues aroundheritage. Emotional intimacy with her parents was out of the question, "I can't do it infront of them. I still have a lot of fear. And it's not fear of getting hurt now. But it is fearthat.. .1 know my mom is trying". To Alison, expressing intimacy with her parents, even asan adult, represented a form of self-indulgence with the potential for hurtfulness. Shenever spoke of any close women friends. And, at 33, she was currently involved in her veryfirst real relationship with a man. Even so, Alison was happy with him but she was afraid ofherself; afraid that she would do something to jeopardize the relationship. She worriedthat she overdid things, i.e., making way too much food for a small party.. .over-compensating and taking too much control.Patterns of ExperienceThroughout the course of treatment, an overall pattern of experience among thewomen emerged. The women exhibited a cycle of transformation which documented theirmovement between two poles, from a place of sickness and great discomfort to a place ofhope and an understanding of the possibilities of health. The transformation began in thedestructive 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 oftransformation: she experimented with the possibilities of change through oscillatingbetween 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 healthfor longer periods of time. The results of the transformation revealed the final phase: ahealthy place ostensibly the antithesis of the destructive phase.The destructive phase. Each of the women saw themselves as surviving life ratherthan actively living it. None felt they were existing anywhere near their potential. They allfelt they were physically alive but spiritually dead. The women perceived themselves asabsolute failures desperately wanting to change and yet feeling completely incapable of150doing so. For each of the women, the world was a black and white prison: they feltsentenced to an eternity in the blackness whilst being tortured by the sight of anunreachable vision of the white light.Channelling behavior.  All of the women had experimented with a number ofmethods by which to cope with existing in the destructive phase, especially through the useof alcohol and drugs. However, the bulimic behavior was the longest lasting and mostvirulent method. According to each of the women, abusive eating differed from the use ofdrugs and alcohol in that it offered, temporarily: feelings of extraordinary power andcontrol; 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 theworld; a method by which to avoid horrific feelings of aloneness, abandonment and theaccompanying fear through spending time with food as friend to fill up the blackhollowness; it earned attention and highlighted a specialness; it enabled a kind of satisfyingform of self-punishment, a kind of psychic suicide; and bulimia offered a method by whichto buy some time-out, to have an 'excuse' to do nothing.The restorative drama phase. The timing of the inception of the restorative dramavaried dramatically for each woman but the pattern was similar. It began with theexpression and exploration of previously unaccessed emotions. The genesis of accessingthese emotions began when the women were asked to reflect on their inner healing self. Atthat moment, each woman was able to stand back from her perception of reality to imaginewhat she could create in its stead. She considered the ingredients required to develop asupport system conducive to her being able to exist in a healthier way in the world. Eachwoman began to fathom that she had an opportunity to take control of her emotions, toredirect her course in life, and to see the potential for fuelling herself from the insiderather than relying on the outside. This realization required some concrete thinking suchas: how does one define and strengthen boundaries in order to feel safe to express oneselfin the world? Once concrete goals were identified, each woman began to visualize how her151goals could be realized. Each woman began to gently experiment by using her newlydiscovered potential in real life situations such as standing up to an intimidating person andholding 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, ranback to her 'mother' (binge eating) when things became too overwhelming. Then shewould set out again, this time going a little bit further with a little bit more confidencebefore 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. Forexample, Cynthia stated clearly, "fear makes me eat, throw up, exercise, see my friends, fearof rejection, being unbeautiful, looking in the mirror". Changing to a new fuel ofconfidence 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 fundamentalmeaning about survival in the world. Each of the women fought an important internalbattle in this phase relating to surrender. Initially, for each of the women to surrendermeant 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 ofthe women was able to glean some very tangible guidance and suggestions for proceedinginto a new, healthy world. Setting clearer boundaries, meditating, and using difficultexperiences to learn in a bigger context were all examples of concrete suggestions cited bythe women.Conversations with the inner healer appeared to dovetail with the development of asense of personal spirituality which also appeared to be an important component in the152restorative drama. Each of the women was quite adamant in their sense of the differencebetween the inner healer and God. It was almost as though the inner healer was a personalangel which they felt was always in them, with them, and watching over them. They allperceived God to be an entity related more to the goings on of the external world aroundthem. Alison articulated it this way, "it's like it protects me outside but the bird protects meinside. And I think God is protecting me from the things outside of me...I will always betaken 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 andembraced during the restorative drama also brought its own set of transition issues. All ofthe 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 feltoverwhelmed at the prospect of actually feeling responsible for themselves without thesafety of the protective shield that had been afforded by their bulimic behavior. Thepresence of transition issues ensured that the nature of the restorative drama was to andfro between the two poles rather than unidirectional. Each of the women regressed back tobulimic behavior at some point during the treatment even though things 'seemed' to beevolving positively. They appeared to need to acclimatize to wellness. Just as a victim ofhypothermia can not be placed in a tub of hot water immediately, or a fasting person cannot break a fast by gorging on a large meal, the bulimic women appeared to have a level oftolerance of foregoing their bulimic behavior with which they were comfortable. The morefamiliar they became with the new world of wellness, the longer they appeared to be ableto exist in that world without requiring a visit to the darker, more familiar comfort ofbulimia until finally they could let go of that world altogether.The transitional drama phase. For each of the women, the transitional drama wasthe result of much exploring and experimentation with new possible ways of living. It wasthe realization of courage summoned to deal with a somewhat frightening, unknown way ofbeing in the world. Each of the women attempted to exist for substantial periods of time in153a world of non-bulimic behavior. They pondered what it would mean to be moreemotionally intimate. They faced the fears of being well, of taking responsibility for theiractions, 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-goinggrowth and change. The growth and change had been reflected in the evolution of each ofthe women's symbols for their inner healers: Alison's seagull had evolved from sitting in thepit of her stomach with his back turned toward her into a happy bird flying along thewater's edge; Sonya's inaccessible male wizard had transformed into a smiling open-armedgirl 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 arainbow of colours including the flesh tones of a living person.Result of transformation. The results of the transformation for all three womenwere of an understanding of new options and choices available to them. The follow upsessions made it apparent that each of the women was still adjusting to adeptly, andcomfortably being in a world of health. Each woman felt she was on an idiosyncratic roadto health which she was confident she could follow. Cynthia grinned, "I feel like I havechanged. It's like I am much more than just me. Its like there is a whole different personrunning 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, andpart of the sixth and final week of our work together, she had slipped back into fulldespondency 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 moodand moving her out of a constant state of suicidal ideation.Alison reported she was not feeling deprivation, but she was having difficulty withTRUST: that it would be okay; that her slight weight increase would not balloon but wouldstabilize into a new way of being. She was having trouble learning how much she should154eat 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 shewas bulimic. Before she used to be able to go into a cocoon. Now she had to face life headon. She clarified, "The compulsion is still there but it's different because before I had nochoice. Now I do."Summary of TransformationsAll three women experienced unique and yet similar manifestations of the first twophases of the cycle of transformation. Cynthia, Sonya, and Alison were each deeplyensconced in their respective destructive phases effectively channelled through the vehicleof bulimia. During the restorative drama, all three women experimented courageously withminiature 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 comfortof bulimia only to rebuild again once they had regrouped.The courses of the three women began to substantially differentiate during thetransitional drama phase. Specifically, Cynthia and Alison appeared to have firmly plantedtheir feet in a new landscape of perceptions. They had learned how to use their innerhealer in times of stress, for comfort, and for advice. They had experimented with assertingthemselves in previously difficult situations using a concrete game plan. They werebeginning to entertain the prospect of accepting their pasts, and taking on responsibility fortheir 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 ableto access on a regular basis.Sonya was not prepared to move as quickly into a different place for herself in theworld. Sonya may need to spend considerably more time experimenting in the restorativedrama phase before she feels comfortable moving onward.155VI. DISCUSSIONStatement of FindingsThirteen themes were observed over the course of treatment with each of the threewomen. 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 phenomenologicalresearch. They were: fear of losing control leading to feelings of abandonment; the use ofbulimia as a protective shield; a desire to purify; and global and food-specific shame andguilt. Nine themes extended findings from previous research. They were: a sense ofGodlessness, self-doubt, feeling like a freak, opposing attitudes/desires on a single issue,self-pity, disenchantment with the perceived female role, exceptional concern for theperceived 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 bulimicwoman's experience, was identified charting her journey toward healing.LimitationsTo 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 havereplicated the same phenomenon under different conditions" (p. 21). He suggests furtherthat, in reality the results of the experimental approach are more generalizable totheoretical propositions than to populations or universes. From this perspective, casestudies may provide results that are just as valid as "true" experiments in that they too aregeneralizable or of relevance to the testing of theoretical propositions. This multiple-casestudy led to the identification of several themes which may serve as the basis for furtherexploration of these themes as theoretical propositions.156Only 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 bodysize and body dissatisfaction is significantly different from women. These results can not beextrapolated to bulimic men. Further, the age range was limited to 20 to 35 year olds in anattempt to control for potential confounds of generational differences in body perception.The experiences of bulimic teenage girls and older bulimic women may be substantiallydifferent from what was documented in this study.The choice of clients from the self-help group Overeaters Anonymous (OA) alsocreated obvious restrictions with regard to the potential generalizability of results. The factthat the women who participated in this study were from OA meetings suggests a certainlevel of awareness about their disorder and a certain level of motivation to overcome it. Itwas 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 directexperience of eating disorders ensured a deep commitment and sensitivity to the study, thatdirect experience may also have represented strong opinions which could have functionedas blinders during data collection and analysis.Clearly, a fair amount of opportunity existed for researcher bias. This may beconsidered a marked weakness in the design which could compromise the validity of thestudy. However, as Yin (1989) points out, "internal validity is a concern only for casual orexplanatory studies" (p. 43). This study was not attempting to explain but to clarify atheoretical portrait.Finally, in an effort to respond to individual differences in each client, no setnumber of drawings was required during each session. A difference in the number ofdrawings across clients may have contributed to a confound arising out of a lack ofhomogeneity of treatment.157Implications for TheoryThis section examines the findings of this study in relation to existing theorypreviously cited in the literature review in two parts. The first part explores how the majorfindings of this study have implications with regard to supporting, and extending existingtheory. None of the major findings appeared to invalidate past research. Support of theoryconstituted the replication of that theory within and across each of the case studies. Anextension of theory constituted the discovery, or honing, of findings which had not beencited in previous research. The section also identifies minor findings as they related tobackground information introduced in the literature review.Major findings. Many pieces of phenomenological research were supported by fourunits of meaning in this study. Fear of losing control leading to feelings of abandonmentwas a theme which dovetailed with, and validated, a fair amount of existing research. Thisfinding substantiated discoveries suggesting that bulimic women seek control in a variety ofways 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 morefear of rejection and loneliness. The unit of meaning which identified that bulimics usebulimia as a protective shield supported Swirsky's (1991) finding that bulimics use thebinge/purge cycle defensively and Herrington's (1991) findings that bulimics use the cycleto isolate. The unit of meaning of global and food-specific shame and guilt supported theexisting research of Frank (1989), Neufeld (1983), and Reynolds (1991). Finally, the themeof a desire to purify was directly identified in Neufeld's research. Indirectly, this unit wascited in Reynold's observations that bulimic women embrace feelings of contamination andself-disgust and in Hsu's (1990) research which suggested that bulimic women often feeldirtiness in the early stages of a binge.Nine of the findings appeared to be extensions of existing research. The theme offeeling like a freak, moved beyond Grissett's (1991) observations of the bulimic's self-158perceptions of social incompetence in that the women in this study did not simply feelawkward 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 ofa 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 threewomen as well. This finding extended research through recognizing that the combinationof various existing findings points to the presence of a clash of attitudes and desires inbulimic women. For example, Kramer (1991) found bulimic women were more likely to beinvolved in dependent, enmeshed intimate relationships while Worth (1989) found theissue 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 notidentify with the traditional feminine role. The theme of disenchantment with theperceived feminine role furthered that finding through suggesting that, at times, each of thewomen fantasized about being a male.Of all the phenomenological research to date, Neufeld's (1983) work appears tohave travelled the most similar ground to that covered in this study. Her observationsrepresent the foundations of several themes charted in the descriptive framework. Thesefindings seem to have honed her work into more specific descriptions of how her themesmight manifest. Neufeld's theme of being-for-others is specifically expressed in the themeof exceptional concern for the perceived down-trodden. Neufeld's theme of fear of fear ofrelationships is clarified through the unit of meaning of fear of intimacy by citing thespecific element of what is feared about relationships. The theme of self-doubt furthersNeufeld's (1983) theme of invalidation of perceptions in that this finding suggests an evendeeper experience of negation in the bulimic woman moving from an external to aninternal focus. Neufeld's theme of sense of obliviousness and depersonalization of self wasextended through the theme of a sense of Godlessness through moving from a sense ofemptiness into specifically recognizing the nature of the emptiness. Finally, Neufeld's159theme of fear of separation may be connected to the theme of a memory of an unsafechildhood. This connection however, seems to be more of a parallel one. The theme ofmemories of an unsafe childhood and the fear of separation appear to be complimentarycomponents in that they may both be perceived as impasses to both the successfulcompletion of childhood and the successful transition into adulthood.The other component of the descriptive framework was: the story of the pattern ofexperience which also appears to be an extension of theory. Although Hsu (1990) hasconducted research following the binge-vomit cycle, this study appears to be the first forayinto exploring the larger cycle of the bulimic journey toward recovery and healing.A common orientation. In reflecting on the coherence of the thirteen themes, howmight they come together to embody a single orientation? The common element fromwhich all of these themes appear to emanate is the bulimic's core belief that they arefundamentally flawed. This belief manifests itself in the form of the thirteen themes. Thefollowing paragraphs represent a speculative effort to understand how the themes may, infact, be different expressions of one fundamental orientation.The four findings in the study which validated existing phenomenological researchcan all be reflected upon as attempts by the bulimic to avoid the exposure of theirfundamentally flawed being. The fear of losing control leading to abandonment appears tobe directly linked to the fear of being exposed: the bulimic woman believes that if she doesnot stay in control of herself, her environment, and especially her food, she will become fatwhich will lead to rejection. The use of bulimia as a protective shield appears to functionas a method by which to avoid having their perceived 'flaw' discovered through creatingisolation. The desire to purify appears linked to the feeling that if the bulimic couldsomehow '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'ssense that she is unable to totally purify herself for any length of time. Because the bulimic160is 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 viewedwithin the common orientation of being flawed. A sense of Godlessness may be related tobulimics' inability to access or experience unconditional love in any way: they are internallyinsulated from even themselves. Similarly, self-doubt may be viewed as anothermanifestation of a lack of self-acceptance. The theme of feeling like a freak shores up thebulimic's belief that she is flawed, and, by definition, deserves to be isolated from everyoneelse in the world. The presence of self-pity appears to function as a 'friend' of sorts. Thatis, 'if I am going to be isolated because I am fundamentally flawed at least I can comfortmyself with a familiar feeling'.Disenchantment with the perceived female role leads to further feelings ofalienation in that bulimic women do not even feel that they resonant with a group withwhich they 'should' somehow connect: their gender. Wooley and Kearney-Cooke mightsuggest that this theme is ultimately "traceable to problems in the construction ofwomanhood" (p. 479). Exceptional concern for the perceived down-trodden is a themewhich appears to evolve out of a feeling of simpatico with other 'freaks'. Yet a connectionwith 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 themeof a memory of an unsafe childhood further substantiates the presence of an immutableflaw in that bulimic women appear to have seen themselves as profoundly different fromothers even as children.The theme of fear of intimacy dovetails into the fundamental flaw: if a relationshipbecomes too close, the bulimic will be found out and rejected accordingly. The connectionbetween the theme of fear of intimacy and isolation may initially seem a bit confusing: if aperson is terrified of isolation, why would they not covet the opportunity for intimacy? Itmay be that the thought of intimacy is one of the most frightening prospects a bulimic could161face 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 withthemselves and others more than anything but that need may make the prospect of failuretoo frightening. Root, Fallon, and Friedrich (1986) point to a number of socioculturalcontributions which may lead to, or exacerbate, this theme such as the negative labellingwhich 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'sconviction that she possesses a fundamental flaw. It followed the bulimic woman'smovement between two poles: from a place of profound near-death sickness to a desire tofirmly grasp and live life. The healing journey was not so much the ability to irradicate theperceived flaw as it may have been learning to accept her flaw and to love herself, flaw andall.Minor findings. Other phenomenological findings in this study were only applicableto one, or sometimes two, of the three women. What follows is a reflection on thosefindings in light of existing research cited in the literature review.As with the phenomenological research, many of the discoveries made in this studysupport existing research. Printz's (1989) findings, regarding bulimic feelings of beingunable to live up to the expectations of parents, were really only relevant in the case ofAlison.With regard to biological factors, Sonya's case may be relevant. In particular,Bendfeldt-Zachrisson (1992) noted a possible common etiology between bulimia andaffective disorders which may have been present in Sonya. Throughout our sessions, Sonyaexhibited mercurial mood swings. At the end of our work together, I suggested that Sonya162consider 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 thebulimic experience in all three cases. Cynthia, Sonya, and Alison all reported varyingdegrees of difficulty with boundaries, conflict management, and support for autonomy ascited by Connors and Morse (1993). All three women appeared to perceive inadequatesocial support from both friends and family (Grissett, 1991). With regard to the effect ofsibling relationships (Lewis, 1988), Sonya and Cynthia both expressed envy of their sistersseemingly better grasp of life although they did not appear to exhibit jealousy to the pointof their daily functions being impeded.Sexual abuse was another consideration cited in the literature. It was present in twoof the three cases in this study. Both Sonya and Cynthia, who were sexually abused, bingedmore frequently than did Alison, who was not sexually abused, as Waller (1992) hadsuggested would be the case. Zerbe's (1992) observations were also corroborated by Sonyaand Cynthia in that they both responded to their childhood sexual trauma with sexualpromiscuity in adulthood.In considering body image, all three women were resolute in their desire for asocially sanctioned thin body (Wiseman, 1992). All three definitely overestimated the sizeof 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 peoplethought above and beyond their own opinions, judgment and intuitions, as Shisslak andPazda (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-thesisof those findings as observed in this study. Each of the women appeared to be very pleased163with themselves whenever they accomplished anything deemed of merit. For example, theyall appeared very pleased with themselves when they discovered their abilities to accessinternal images. Also, some findings simply felt murky and confusing in relation to thediscoveries made in this study. Specifically, Igoin-Apfelbaum (1985) suggested that bulimicpatients have symbiotic feelings for their mothers with whom they experience "sharedinescapable distress" (p. 164). Igoin-Apfelbaum was referring to the bulimic woman'sbiological 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 PracticeGiven that less than 50% of practicing clinicians who specialize in eating disordersbelieve that a consensus regarding treatment has been reached (Herzog et. al., 1992), anopenness to the findings and potential implications for therapy cited in this study may welllead to additional insights and advancements in treatment practice. In practice, the mostsuccessful therapies to date, cognitive-behavioral therapy, group therapy (Herzog et. al.,1992) or any other therapeutic approach may benefit from an awareness of, and sensitivityto, the nature of the bulimic experience as mapped out in the descriptive framework. Forany 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 mayhelp to facilitate the experience of a deeper therapeutic bond, an opportunity for greaterinsight, 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 ofexperience suggesting a method by which to identify a bulimic's stage of recovery. Theability 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 termsof selecting the most effective treatment approach. For example, a clinician who beginsworking with a bulimic woman may chose to work differently with her if they know that sheis in a destructive mode of the cycle of the restorative drama phase as opposed to simply164the destructive phase. Those two situations may, on the surface, manifest in an identicalway. However, if the clinician is aware that the client has also experienced the restorativecomponent of the restorative drama phase, they can attempt to access the memory of thathealing experience and work with the client accordingly. The above scenario suggests thatan awareness of the pattern of experience may help to identify a system by which theclinician can more accurately assess the state of the bulimic client thereby providing anopportunity for more focussed treatment plan.Implications for Future ResearchThere may be several future possibilities for continued research to be developedfrom the information uncovered in this work. First, a replication of this treatment programmay be warranted in order to test the stability of the thirteen themes, the pattern ofexperience, and the possibility of a common orientation of isolation mapped out in thisstudy. Second, different methods of exploring the findings of this study may be useful. Asurvey method, for example, may be an effective format in which to validate the study'sfindings. Third, an expanded, and varied sample could be considered including a largernumber of participants, a broader age range of participants, a separate study on bulimicmen, and the inclusion of bulimic individuals from sources other than 0.A.. Fourth, it ispossible that a longer treatment period could enhance the depth and breadth of insightgarnered. For example, how might the cycle of the pattern of experience develop over alonger period of time?Fifth, this study both validated, and extended the expression of imagery work ofboth Miller (1991) and Hill (1992). All three women were slightly, or very, uncomfortablewith drawing sometimes or all the time; although all acknowledged that drawing had beenan effective way of expressing some difficult-to-express feelings. However, the guidedimagery was appreciated unequivocally throughout the session work. In fact, during thefollow up session each woman spontaneously volunteered positive comments about theongoing benefits experienced on a daily basis as a result of having participated in the165imagery exercises. Each woman alluded to her personal inner healer symbol as somethingfrom which she was regularly able to garner internal strength. The success of the guidedimagery exercises suggests future research into the use of guided imagery as a adjunctivemethod by which to understand and treat bulimics may be very fruitful.Sixth, this thesis did not extensively explore sexuality as it may effect bulimicwomen. Pope (1992) found no differences in reports of childhood sexual abuse in bulimicsversus the general population. However, Thackwray (1991) has suggested that the 49% ofbulimic women who do report histories of sexual abuse may still be underrepresenting theactual number of sexually abused bulimics. Further specific research into the experience ofbulimic women and sexual issues may render some useful data such as developing a moredefinitive understanding of the role sexual abuse may play in the bulimic experience.Finally, there are many implications for future research when bulimia is viewedthrough the kaleidoscope of sociology. These research findings offer an opportunity to addto an ever-growing speculative discussion about how bulimia may be viewed within a largersocietal context. The following few paragraphs explore the themes discovered in this studywith questions and speculative comments which could lead to intriguing pieces of futureresearch.A disenchantment of the perceived female role may have been a way to freeze orimmobilize the perceived obvious and subtle inequities in the bulimic women's worlds. Inconscious, and subconscious ways, the women in this study abhorred and resented theindelible stamp of 'second sex' they felt was printed on their foreheads. Changing the shapeof 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 isdirectly connected to her issues around gender roles. She feels that God and men are in anOld 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 against166the glass" (p. 4). Or a sense of Godlessness may be sparked by other influences. Is thistheme indicative of a general societal dearth of spirit? Maybe the binge/purge cycle is adesperate attempt to feed the "hollow blackness" of a starved spirit within the confines ofan advanced capitalistic society's narrow vision of perfection. Maybe bulimia is, in fact, ahealthy reaction to a reality wherein one feels ostracized if one is not unnaturally slim butone feels completely compromised by succumbing to dogma if one is unnaturally slim. Itwas intriguing that each of the women felt that to surrender to healing meant to becomefat. It was as though they could not conceive of a middle ground: to embrace health andspirit 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 ofopposing desires on a single issue. The 'damned-if-you-do-damned-if-you-don't' conundrumseems to permeate many facets of the bulimic's life. The bulimic woman appears to possessan enormous fear of being abandoned while simultaneously being terrified by the prospectof intimacy. She condemned herself as a worthless "freak" and yet appreciated the innerrichness of the down-trodden "freaks" of society above any other people. She doubted herown perceptions and yet the prospect of surrendering any vestige of control she felt she didhave to another was untenable. It was as though this conundrum was an elegant way toremain frozen, ironically, in the hollow blackness she abhorred yet knew so well. Perhaps itwas the only solution she could conceive of to feel somewhat safe. At least, in that frozenplace between life and death, a half opened coffin of sorts, one may be able to ferret outstrangely dependable comforts. For example, Alison described her self-pity as a kind offriend 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 ofexceptional 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 release167of the bulimic woman's own self-perceived oppression during the moments in which she isproviding help to others in whom she can see facets of herself. It is possible that thebulimic woman can access, and have deep compassion for, the ostracized, unchampionedpart 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 toprovide tenderness and love to herself. Altruism, albeit selective, may well be a way toexperience a kind of communal belonging that otherwise goes unnurtured in the bulimicheart. Many would argue that, on the whole, North American society has retreated fromcharitable work at the grassroots, community level over the past two decades. Perhapsthere is a correlation between the overall level of communal interaction and caring and theNorth American explosion of bulimic behavior. Many would also argue that a sense offamily, literally, and communally, is an integral part of a feeling of safety in childhood. Thedearth of that perception may lead to a further erosion of being able to learn about andtrust both the experience of intimacy and self-perceptions.As generations coming of age in the atomic age, perhaps nothing in childhood feelscompletely 'safe' or completely pure, anymore. Perhaps the global shame and guiltharboured by bulimics along with their desire to purify is a response to a globalenvironmental problem as much as it could be responding to a more personal crisis. But, ifthat were the case, why are 95% (Wolf, 1990) of bulimics women? It may be that, asWoodman (1982) has observed, "the experience of the feminine is the psychological key toboth the sickness of our time and its healing" (p. 132). Sonia Johnson (1987) suggests thatexploration of the female experience may lead to a new global consciousness therebysetting 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 numerousquestions, and much more research pursuing a broad spectrum of possibilities. Further, the168speculative discussion suggesting a common orientation of a fundamental flaw alsogenerates ideas for research which may reach beyond the scope of eating disorders intoother addictive behaviors. For example, are the themes identified in this study relevant toother populations such as alcoholics or substance abusers?SummaryFour findings in the study supported existing phenomenological research. Theywere: fear of losing control leading to feelings of abandonment; the use of bulimia as aprotective shield; a desire to purify; and global and food-specific shame and guilt. Ninethemes 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, disenchantmentwith the perceived female role, exceptional concern for the perceived down-trodden, thememory of an unsafe childhood, and fear of intimacy. A final finding related to thecharting 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 effectivetool for gleaning insight into the bulimic experience across all three case studies. As acorollary of the discovery of those insights two of the three women were well on their wayto overcoming bulimic behavior when the follow up sessions were conducted. The thirdwoman used her new self-knowledge to enable a decision regarding the commencement ofa course of anti-depressant medication which resulted in a very positive change in hergeneral mood.169ReferencesAchterberg, 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 primarychildren. Elementary School Guidance and Counseling.Allan, J. (1978). Serial drawing: A therapeutic approach with young children. CanadianCounsellor, 12, 223-228.Amari, D. (1986). The use of clay to form potential space with a bulimic patient. PrattInstitute Creative Arts Therapy Review, 7, 13-21.American Psychiatric Association (1987). Diagnostic and Statistical Manual of MentalDisorders (3rd ed. revised). Washington, DC: American Psychiatric Association.Arkowitz, H. (1989). 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The role of blood glucose in binge eating behavior. DissertationAbstracts 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 ofPsychiatry, 161, 90-93.Williamson, D. (1990). Assessment of eating disorders: Obesity, anorexia and bulimianervosa. New York: Pergamon Press.Wiseman, C. V., & Gray, J. J. (1992). Cultural expectations of thinness in women: Anupdate. 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: InnerCity 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 eatingdisorders: 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 toSimpson and Ramberg. Journal of Sex and Marital Therapy, 18(1), 55-64.175Zulkosky, P. (1984). The wise woman in guided imagery: A feminist interpretation.Dissertation Abstracts International, 44(8-A), 2363.176APPENDIX ASUBJECT SOLICITATION FORMDEPARTMENT OF COUNSELING PSYCHOLOGYUNIVERSITY OF BRITISH COLUMBIAI am currently conducting research for my Master's Degree in CounselingPsychology on the use of Art Therapy and Guided Imagery in working with people who arebulimic. The goal of the project is to provide participants with meaningful, new insightsinto their body image and eating behavior. The project involves 1 one-hour case historyinterview; 12, one-hour sessions, and 1 one-hour follow-up session all of which will takeplace at UBC. All sessions will be conducted under the supervision of a UBC CounselingPsychology faculty member and will be kept strictly confidential. During the sessions, youwill 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 guidedimagery exercises which involve simple relaxation and visualization techniques. Nodrawing skill is required. If you are interested in participating please answer the questionsbelow and read and sign the attached consent form.PLEASE PLACE APPROPRIATE NUMBER IN THE SPACE PROVIDED:+^+^+^+^+1 2 3 4 5TotallyNeutral TotallyDisagree AgreeI. DURING THE PAST 3 MONTHS I HAVE BINGED AT LEAST TWICE A WEEK.II. I FREQUENTLY ENGAGE IN THE USE OF SELF-INDUCED VOMITING INORDER TO PREVENT WEIGHT GAIN.III. I FREQUENTLY ENGAGE IN THE USE OF LAXATIVES OR DIURETICS INORDER TO PREVENT WEIGHT GAIN.IV. I FREQUENTLY ENGAGE IN THE USE OF VIGOROUS EXERCISE IN ORDERTO PREVENT WEIGHT GAIN.V. I FREQUENTLY ENGAGE IN THE USE OF STRICT DIETING OR FASTING INORDER 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 ANDWEIGHT.177APPENDIX BUBC LETTERHEADSUBJECT CONSENT FORMDEPARTMENT OF COUNSELING PSYCHOLOGYUNIVERSITY OF BRITISH COLUMBIADate:^ agree to participate in a researchproject entitled, "Treating bulimics: The use of imagery to heal" which is being conductedby 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 willalso be a one-hour, follow-up visit in January, 1993. The procedures to be followed and thepurposes of the study have been explained to me. As I understand it, the study requires meto discuss issues surrounding, and including, my eating habits and my body image. I alsounderstand that during the course of the sessions I may be required to create severaldrawings and participate in guided imagery exercises consisting of relaxation andvisualization techniques. I also understand that my sessions may be tape-recorded and Iwill be asked to complete a number of questionnaires. I understand that any questions thatI may have during the course of the project will be addressed and that I will receivefeedback regarding my participation.I understand that there are no foreseeable risks to my health or safety. I understandthat I may refuse to participate and that I am free to withdraw at any time. All informationis strictly confidential. While findings may be used in future studies or publications therewill be no identification of me personally on any records. I understand that I will receiveno compensation (monetary or otherwise) and that my current participation does notobligate me to participate in future.I have read and understood the content of this consent form, a copy of which I havereceived, and agree to participate in this study.Signature:1784i'vo,ofFigure C1.2.The coffin.180Figure C1.3.Living room.181Figure C1.4.How the world sees me.182Figure C1.6.My Inner Healer,184'710c.)Figure C2.2. The Path.,-"`Figure C3.1.The Grey Filter Mask.187Figure C3.2.Closeup of the filter.188Figure C5.1.The feeling of being a prostituteFigure C5.2.No.Figure C8.1.Red heart.Figure C8.3.Third drawing.Figure C10.1.The Warrior..4194Figure 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.197Poppa.ti■  .  M=P-1CDCIIo —■iss)t..)o0Figure S1.5.What I see when I look in the mirror.\202IV0L.)Figure S2.1.Male and female.204Figure S6.1.The heart.-266Figure S9.1.Little black devil.207Figure S12.1.How the world sees me.Figure S12.2.What I see when I look in the mirror.209•AS,tsJ0Confusion.211Figure A1.2.Isolation.Figure A1.4.How the world sees me.214Po•--4co)8^... ^It^CD 1— Oa^I■1 ^,.95 (t)0 >.^5*^!-/1s --CD4.01.-1tvI—,Cn4..,^ot-•^..;,—;•zCD^"I-ICD>g.n^!::":-1tvI-,0lNr-iolgwi....,..cNi^.<cNi 0.‹ 0cu ,41.^+4=E={ 1 li)4 4<4cugFigure A2.2.Black Self.218Figure A2.3.Feelings for parents.219Figure A3.1.The yelling man.220Figure A3.2.The protector Aura.221Figure A4.1.Male and female.222Figure A4.2.Twelve year old.223Figure A5.1.Terror and vertigo.Figure A5.2.My spirituality.225Figure A5.3.The nagging doubt.226Figure A6.1.What I lose by giving up binging.227Figure A7.1.Thick wall.,2280CDco)0ro .0P07. t  PCDr:.-8t...)L,..)0Figure Al2.2.What I see when I look in the mirror.233nrce)clFigure A11.1.The seagull.231


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