This was a research project from last year based on analysing Yoga in the treatment of Bulimia Nervosa and also Gestalt Psychotherapy. Both are holistic and clinical frameworks which have mounting evidence in the effectiveness of treatment. Worth a read for those looking to explore options of treatment in their eating disorder or with disordered eating/body image.
This paper will present Gestalt Psychotherapy as an effective relational, experiential and embodied modality in the therapeutic treatment of Bulimia Nervosa (Fodor, 1996). In the first section I will explore, outline and define the allopathic description of Bulimia Nervosa, utilising the Diagnostic and statistical Manual, Edition 5 (DSM V). This will then move in to an overview of how this clinical issue is defined through a Gestalt therapy lens. The second section will explore Yoga as a therapeutic comparative modality in the treatment of Bulimia nervosa, including definitions, characteristics and yoga’s understanding of a client that presents with this clinical presentation. This section will also look at comparisons of gestalt therapy and therapeutic yoga. The final section will comprise of gestalt psychotherapeutic interventions reflecting how a gestalt psychotherapist would employ the methodology of Gestalt when working with Bulimia Nervosa. This analysis will include the four theoretical pillars of Gestalt Psychotherapy namely, field theory, phenomenology, experimentation and dialogue. This section will also identify any ethical challenges that could potentially emerge for a Gestalt Psychotherapist working with the presentation of Bulimia nervosa in the clinical setting.
To understand Bulimia Nervosa (BN) it is helpful to know it’s common definition in the clinical field. Diagnostic criteria for BN in the updated Diagnostic and Statistics Manual for Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) are:
- Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
(1) Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is larger than most people would eat during a similar period of time and under similar circumstances.
(2) a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
- Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
- The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 months.
- Self-evaluation is unduly influenced by body shape and weight.
- The disturbance does not occur exclusively during episodes of Anorexia Nervosa (
The level of severity may be increased to reflect other symptoms and the degree of functional disability. An average of 1-3 episodes of inappropriate compensatory behaviors per week. Moderate: An average of 4-7 episodes of inappropriate compensatory behaviours per week. Severe: An average of 8-13 episodes of inappropriate compensatory behaviors per week. Extreme: An average of 14 or more episodes of inappropriate compensatory behaviours per week.
(APA, 2013, p. 345)
It is reported that 12% of 913,986 people in Australia experience Bulimia Nervosa, a serious and potentially life threatening illness (The Butterfly foundation, 2012). On average it usually takes an individual 8 – 10 years before seeking therapeutic support (Pfluger, 2014). Poor body image is considered the leading risk factor in the development of the intricately complex condition, with other risk factors such as Socio – cultural, environmental, genetic, interpersonal, psychological and physiological components being influences in the development (The Butterfly foundation, 2012). These factors often contribute toward making treatment difficult, however new research is starting to indicate that the use of the body in treatment supports recovery of eating disorders (van der Kolk, 2014). Furthermore, a report from The Butterfly foundation in 2012 regarding eating disorders and body image found that the ability to resist cultural pressures and receive relational support greatly counteracts the societal expectations and improves the chances of recovery (The Butterfly Foundation, 2012). It is for this reason that Gestalt psychotherapy makes for an appropriate and effective treatment methodology.
Gestalt Definition of Bulimia Nervosa
Gestalt psychotherapy is an existential, relational and embodied growth model that views individuals as organismic self-regulating beings (Perls,Hefferline & Goodman, 1951). Many Gestalt therapists have been opposed about putting diagnostic labels on people for quite some time, instead Gestalt therapy is a process oriented and well – established relational methodology that is concerned with how an individual makes contact with others, themselves and their wider environment (Crocker, 2008). Gestalt believes the self is created in the process of making contact with the environment and if the individual does not get their needs met, the organism will self – regulate and find a creative adaptation that supports their survival (Mackewn,1997). It is useful to understand the framework of the contact cycle to engage more fully with the idea of self-regulation and contact (Clarkson, 2004). The contact cycle shows how a person makes or breaks contact and how they may come to self – regulate through engagement with Bulimia Nervosa (Pfluger, 2014; Wheeler & Axelsson, 2015). Raw sensation (data), awareness, mobilization, action, contact, satisfaction, assimilation and withdrawal are the many stages that comprise the contact cycle (Polster & Polster, 1973). Gestalt therapy proposes that clients can interrupt fulfilling the contact cycle through individual creative adjustments, such as introjection, projection, retroflection, deflection, desensitisation, egotism and confluence at the contact boundary (Mann, 2010). Bulimia Nervosa is the de-sensitizing and retroflection (Fodar, 1996; Mann, 2010) creative adjustment that an individual engages in as a negotiation to unacceptable sensations at the contact boundary (Gillie, 2000).
The following sections will analyse and examine the different approaches that Yoga and Gestalt psychotherapy use when faced with the presentation of a client with Bulimia Nervosa the the therapeutic setting.
Yoga in the treatment of Bulimia Nervosa
Yoga is a somatic and embodied practice that is increasingly being used in the psychotherapy setting supporting those experiencing Bulimia Nervosa (Costin & Kelly, 2016). Extreme body image disturbances such as Bulimia can be conceptualized as a dualistic split between mind and body or a spiritual crisis (Garrett, 1996; Lester, 1997) and as most widely researched modalities (e.g., cognitive behavioural therapy) are ineffective for a large number of Bulimia patients (Fairburn, Cooper, & Sharan, 2003), the space for body and mind practices, such as yoga is being utilised and researched further as a therapeutic option (Dittman & Freedman, 2009). Yogic philosophy offers a perspective that joins the two and provides a methodology for unification of mind, body, and spirit (Dittmann and Freedman, 2009). Research is indicating that “active embodiment is a necessary prerequisite for eating disorder recovery, and therefore recommends body – based practices that facilitate body awareness as treatment” (Braun, Siegel & Lazar, 2016, p.59). A further explanation of yoga is necessary to grasp this approach.
The original meaning of yoga is union of the body and mind and it is a holistic and experiential teaching that comprises the eight – limbed path towards realisation of an individual’s true self (Davies, 2013) The first of the 8 limbs, Yama is considered to be a universal morality, Niyama is the practice of observance, Asana is posture practice and is the most readily known part of yoga in western culture, Pranayama is breath control, Pratyahara is sense withdrawal, Dharana is a type of focussed concentration, Dhyana is meditation and Samadhi is unified consciousness (Desikachar, 1995). In the therapeutic and class setting Asana brings attention to the body and how it reacts and responds to different asana (postures), Pranayama is used to bring focus to the breath that allows for an awareness of the present moment by noticing the transitory nature of one’s momentary experience (Brisbon & Lowery, 2011) and Meditation is used to to support heightened concentration, perception and intuition (Cope, 1999). Originally, yoga was taught and developed thousands of years ago to be taught in a student and teacher relationship (Davies, 2013). The teacher would attune to the student’s individual circumstances and would work together on all aspects of the person, taking in to consideration the student’s unique body, psychological make up and what emerges as the direct experience in the moment (Allen, 2016). There has been a move away from this in Western culture, with classes being open to a large number of people, more recently the introduction of yoga therapy, yoga psychotherapy, yoga psychology and trauma sensitive yoga has been reflecting yoga’s original roots (Davies, 2013).
Yoga psychotherapy treatment supports people experiencing Bulimia back to their embodied experience through breath and body awareness (Braun, Siegal & Lazar, 2016). This is facilitated in a number of different ways. Some clinicians report supporting someone on the mat before sitting in the chair with direction guided to a body check-in and then a question about their present state of mind. (Allen, 2016). Breath work might also be included followed by a short meditation or talk therapy (Allen, 2016). Others report utilising Trauma sensitive yoga, an approach developed by David Emerson in collaboration with Bessel van der Kolk, that maintains focus directly on body experience and moves away from talk therapy (Emerson, 2015). There are many other variations of how it is utilised in therapy, however the running theme is that the approaches offer a gentle invitation and enquiry about the way people with bulimia engage with the world (Douglass, 2009). The umbrella of therapeutic yoga research suggests that specific poses have an influence on stress levels and hormones by introducing new tools to understand physical and emotional experiences in the therapeutic experience (Allen, 2016). The research also reflects that Meditation supports an increase in gray matter through areas of the brain that is associated with emotional regulation and empathy, which is said to be greatly impacted in those experiencing Bulimia (van der Kolk, 2014).
Complexities also appear in yoga and Bulimia therapy research (Douglass, 2009). Currently there is only a small collection of specific research on yoga and Bulimia in the therapy room (Allen, 2016). Furthermore, most research conducted on eating disorders and Bulimia reflects varying approaches of the integration in the therapy setting, making it difficult to discern what specifically are the supporting factors (Allen, 2016). Majority of the research agrees that meditation, breath and body awareness are key components, however in doing so, this also inadvertently reduces the holistic framework of yoga and disregards the 5 other limbs that are immeasurable. Such as the non-visual philosophy, spirituality and ethical and moral ways of being in the world (Sorbara Mora, 2016). Additionally, the ancient text where Yoga originates from, the Upanishads, speaks to the importance of nourishing relationships and unfortunately this is also overlooked in the research (Douglass, 2009). In doing so, the impact of the therapist and what emerges in the therapeutic relationship is overlooked (Taylor, 2014). Furthermore, the research conducted aligns with the DSM 5 lens, which implies that the client has a disorder that is in need of being changed by the therapist, rather than looking to other relational factors (van der Kolk, 2014).
There are similarities between Yoga and Gestalt psychotherapy’s treatment on Bulimia and there are also many differences. Gestalt recognises the importance of direct embodied experience and just like the yoga therapists, invites clients in to a gentle enquiry of themselves and their body (Kepner, 2003). The phenomenological method in gestalt methodology offers a full embodied process that includes attunement from the therapist and the use of the therapist’s phenomenological data (Clemmens, 2012). Gestalt understands that where the therapist provides consistent attuning to clients, historical unmet needs will emerge and provide an opportunity at the contact boundary for a new experience to emerge (Taylor, 2014). This differs from the research on yoga and Bulimia, where the therapist is still the ‘expert ‘(Cook-Cottone, 2015). Additionally, yoga’s holistic framework of recognising the totality of a person and their interactions with their environment is much like Gestalt psychotherapy. The main difference worth highlighting is that all the current research in Yoga and Bulimia still comes from the lens of the medical model (Cook- Cottone, 2015). From this lens, the viewpoint contributes most of the dysfunction to an isolated self (Franscetti, 2007). This viewpoint is in stark contrast to the contempory relational gestalt lens on the importance of what emerges in the relationship and the development of self (Wheeler & Axellson,2015).
Gestalt Psychotherapy in the treatment of Bulimia Nervosa
Gestalt therapy methodology is field contextual, phenomenological and a relational paradigm (Wollants, 2012). Bulimia Nervosa is viewed as a disturbance between a person and their wider situation (Wollants, 2012). Today’s society places increasingly more pressure on women and men to meet a societally constructed ideal on beauty (Pfluger, 2014). It is not uncommon for women to introject their sense of self from these ongoing messages and to feel shame for not meeting the societal ideal (Lee & Wheeler, 1996). This is often seen in those experiencing Bulimia (Pfluger, 2014). Additionally, is not uncommon for their boundary emphasis to become heavily reliant on other people’s expectations, rather than on their self’s felt need (Fodor, 1996; Gillie, 2000). Therefore, a Gestalt therapist would work with the introjects of shame, isolation and supporting the individual to make contact with their needs (Pfluger, 2014). They would invite the client, in to body awareness, whilst at the same time using their own phenomenological data to track and attune to the client, working with self as the instrument in support of co- regulation (Fodor, 1996; Clemmens, 2012). It is not unlikely that the person engaging in bulimia is frightened by support, often compounding the shame that already exists (Pfluger, 2014). They are used to hiding and isolating rather than asking for their emotional needs to be met (Fodor, 1996). Where the therapist provides the consistent attuning to the client, this will reflect the therapists interest in the client as a holistic being and in doing so, it is likely that historical unmet needs will begin to emerge, creating an opportunity for the client to have a new and safe experience (Clemmens, 2012). By accessing their phenomenological body awareness and needs, it is hoped that this will also support the client learn to self – nurture outside of the therapy (Fodor, 1996). The therapist would also look to resource the client in the context of their wider field by providing information and referrals for group therapy, psycho – educational and support groups (Pfluger, 2014). It would also be important to provide therapeutic and psycho educational referrals to the loved ones, potentially addressing the wider family system with support (Pfluger, 2014).
Supportive contact in relationship provides an opportunity for transformation to unfold and also invites ethical considerations when working with a client experiencing Bulimia (Kepner, 2003). The dialogic work is incredibly vital in supporting the regulation of affect, which is usually a prominent difficulty from the clients past insufficient validation and co- regulation (Gillie, 2000). The therapists consistent and empathic attunement supports the opportunity for the client to slowly move away from the creative adjustment of bingeing and purging in isolation to gradually coming in to contact with sensations, feelings, needs and a deeper intimacy with self and others (Gillie, 2000). Ethical concerns need to also be taken in to consideration when entering in to dialogical contact with Bulimia Nervosa client. Often if the clients extended field is in stark contrast to what’s unfolding in the therapy room it is not uncommon for the contact of the therapeutic relationship to further perpetuate the cycle initially (Taylor, 2014). Focus on the eating disorder can further increase the shame and trigger a highly dysregulated state (Taylor, 2014). Furthermore, medical complications can accompany bingeing and purging (Ref) Low potassium levels can be a serious byproduct of vomiting and can even cause death in severe cases (The Butterfly Foundation, 2012). Substance abuse, gambling, alcohol abuse and suicidality is also common in the client experiencing Bulimia (The Butterfly Foundation, 2012). Therefore, it is advisable that collaboration with an experienced and knowledgeable General practioner is part of the treatment process, always ensuring that the client is actively engaged in the collaborative process to maintain trust (The Butterfly Foundation, 2012). Additionally, it is important for the therapist to be aware of their own body image perception and introjects, safeguarding the client from further shame and increasing safety in the therapy room (Fodor, 1996).
Experiment is a foundational element of of gestalt therapy that enhances embodied integration (Denham-Vaughan, 2005). The experiment in gestalt therapy emerges in the present moment with the intent of increasing awareness rather than aiming for a particular outcome (Ginger, 2007). Varying ways of experiment can be utilized by the gestalt therapist when working with Bulimia Nervosa (Denham-Vaughan, 2005). Dialogue, Movement, Body awareness and the relationship are all ways that can be used in an experimental way (Clarkson, 2004; Phillppson, 2001). The therapist would utilize heightened body awareness with this clientele to support clarity around their process and also around their body (Ginger, 2007) Most clients with Bulimia report being disconnected from their bodies and as such, heightened body awareness can be increasingly powerful (Fodor, 1996). As such embodied thoughts will emerge and the client will experience a move toward assimilation and growth as processed in the body (Kepner, 1987). It is important to utilize experiments slowly and gradually when working with a client experiencing Bulimia as further fragmentation may unfold (Pfluger, 2014; Taylor, 2014). As shame is usually a lively figure with the client experiencing bingeing and purging, importance is placed on the therapist noticing any signs of its emergence and providing relational support, in doing so, this creates the safe emergency and increases the potential for the client to experiment with new ways of being seen and making contact from a place of choice (Phillipson, 2014; Wheeler & Axelsson, 2015).
Bulimia Nervosa is a serious attempt to self – regulate and manage overwhelming sensations, emotions and unattended needs (Fodor, 1996; Gillie, 2000). This analysis of literature has shown the embodied processes of yoga and has highlighted the effectiveness and short falls of the current yoga methodology in the treatment of Bulimia. In particular, the present literature has highlighted embodied process as an effective tool to working with Bulimia Nervosa, regardless of the way it has emerged in the therapeutic setting. Furthermore, in this highlighting it has comparatively reflected the effectiveness of gestalt’s methodology on embodied process, providing research where Gestalt psychotherapy may be lacking. Additionally, it is Gestalt therapy’s relational, field- sensitive and experiential way that addresses the core challenges of clients with Bulimia Nervosa in a safe and contained space. As the client makes contact with their body experiences, needs and wants in a way that is expressed, supported and actioned, the client will no longer need to engage and regulate through a Bulimic pattern.
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