Art Therapy and Eating Disorders: The Self as Significant Form

By Mury Rabin

Art Therapy and Eating Disorders is a step-by-step approach to a new and extremely promising technique for treating people with eating disorders -- children as well as adults, male and female sufferers alike -- that has proven to be a crucial aid to identification, prevention, and intervention. Mury Rabin demonstrates how her award-winning art therapy technique, known as Phenomenal and Nonphenomenal Body Image Tasks or "PNBIT," can be used by clinicians other than art therapists and shows its effectiveness in combination with diverse therapeutic techniques.

Unlike traditional therapy programs that treat symptoms, this technique focuses on root causes and consists of a series of tasks -- some phenomenal: weight recording, mirror viewing, and body dimension estimates; others not: chromatic family line drawings and body image mandalas. The book includes five case studies that illustrate how the PNBIT technique functions in practice.

• Language: English
• Publisher: Columbia University Press
• Release date: Jul 24, 2012
• ISBN: 9780231507332

Book preview

Mury Rabin

Columbia University Press       New York

Columbia University Press

Publishers Since 1893

New York Chichester, West Sussex

cup.columbia.edu

Copyright © 2003 Mury Rabin

All rights reserved

E-ISBN 978-0-231-50733-2

Library of Congress Cataloging-in-Publication Data

Rabin, Mury.

Art therapy and eating disorders : the self as significant form / Mury Rabin.

   p.   cm.

Includes bibliographical references and index.

ISBN 0-231-12768-5 (cloth : alk. paper)—ISBN 0-231-12769-3 (pbk. : alk. paper)

1. Art therapy.   2. Eating disorders—Treatment.   3. Body image disturbance—Treatment.   4. Self. I. Title.

    RC489.A7 R33 2003

    616.85′260651—dc21

2002034833

A Columbia University Press E-book.

CUP would be pleased to hear about your reading experience with this e-book at [e-mail].

To the individuals who gave up their identity to become subjects in a courageous journey to find their Self

APPENDIXES

1  Extracts of Exit Tape Recordings

a.  Jessica Mason

b.  Claudia Bernard

c.  Heather Allen

d.  Linda Miller

2  Self Report Form

3  Therapist Report Form

4  Sequence and Time Chart

5  Outline Drawing: Figure Selection, Male

6  Outline Drawing: Figure Selection, Female

7  Body Dimension Estimate and Measurement: Linear, Male

8  Body Dimension Estimate and Measurement: Circumference, Male

9  Body Dimension Estimate and Measurement: Linear, Female

10  Body Dimension Estimate and Measurement: Circumference, Female

11  Sandworlds Grid

12  Questionnaires

a.  Eating Questionnaire

b.  Body Contour Drawing

c1.  Self Box Questionnaire

c2.  Comparison of Self Box 1 and Self Box 2

13  Medical Release Form

14  Medical Questionnaire

15  Abstract from The Yo-Yo in Art Therapy: The Use of Art Therapy in Eating Disorders

16  Art Therapy Images as an Index to Suicide

17  Metropolitan Life Insurance Height and Weight Tables and Frame Size Estimate Chart (1983)

18  Abstract from Phenomenal and Nonphenomenal Body Image Tasks in the Treatment of Eating Disorders

19  The Scope of Art Therapy

20  Relationship of Issues in Eating Disorders

21  Figure Selection II

22  Color Chart

23  Tissue Box Estimate

References

Index

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Megan Brown’s recording is included in chapter 5.

Art, whatever form it takes—a painting, a story, a poem, a musical composition, a dance—is always a product of the total being who creates it. It incorporates all of that artist’s inner experiences as well as his multiple environments, including all the people who have been on the landscape of his life: his family and his world. All the good and nurturing things are there and all the negative and challenging experiences as well. They enter the prism of his life force and emerge alchemized in his unique vision. Each expands and humbles at the same time.

I want to say an awesome thank you to the thousands of individuals I have known and whom I treasure. My father’s creative spirit and my mother’s challenges are surely part of this work. My own family, without exception, has been accepting of my dedication and pursuit of each new idea. My art has been the major force that fueled the academic work. My husband, Gideon, and my two children, Brandon and Staton, all authors in their own right, were empathetic, knowing the delicate balance necessary to continue the long and circuitous route, which at times defied the beaten path, on which I found myself.

The generosity of the people who mentored me during my years of learning and working: teachers, academic medical universities, colleagues, friends, and, especially, those in need who came for my help, enriched me far beyond the limits of the roles we had.

In this new venture, the journey of manuscript to book, I appreciate the professional qualities demonstrated by those at Columbia University Press. I am grateful to John Michel, executive editor, who made it seem possible. His response to my first phone call was a cordial invitation for me to take the first step into the unknown, and he led me gently through the intricacies of the process. Thank you. The staff, especially Susan Pensak, senior manuscript editor, were diligent, patient, and tolerant of my concept. I thank them all.

Art, accompanying man on his difficult journey to himself, has always been ahead of him at the goal.

—Carl Jung

The reader who seeks a succinct definition of art therapy will be disappointed. Art therapy applications vary, as any therapy, according to the individual who presents with a particular problem to a therapist who will direct treatment methods applying to that person at a particular time, in a particular setting. Treatment that is based on the definition of a syndrome documented in the Diagnostic and Statistical Manual of Mental Disorders (DSM), which provides guidelines and a number for each disorder, often limit the critera for diagnosis. In the push for efficiency and economy, hospitals are reimbursed for treatment based on these factors and have adhered to the guidelines in the DSM by limiting the number of in-hospital stays allowed for a particular syndrome. The number of private therapy sessions is also restricted. This approach to treatment does not serve all patients.

This book focuses on a method used with obese and anorectic women who were in crisis at the time of entry into the project. The manual (see chapter 4) describes a series of tasks and how to apply them. The case studies (see chapter 5) report on how these tasks served each participant. In traditional treatment programs the addictive problem has been addressed by treating the symptom directly, e.g., for the alcoholic: going off alcohol, for the obese: dieting, for the anorectic: eating more, etc. Where a patient has succumbed to a drug overdose, or for the obese or anorectic in a medical emergency or state of crisis, hospitalization and observation are, of course, necessary. The symptom is not the cause but the result of a missing self-concept. The writer’s experience with each of these populations revealed a common thread—low self-esteem. It was expressed by denial, anger, defiance, perfection. Each of the individuals covered up his identity. The need to identify, recognize, and acknowledge the self-concept comes before self-esteem, positive or negative. The tasks are designed to be a preamble to treatment of the symptoms. Art therapy includes both verbal and nonverbal work. The two hemispheres of the brain are involved. The tasks require the active participation of the client and include crossing the corpus callosum, from right hemisphere activity to left hemisphere activity for each session. While each of the tasks appears to be different, each is really addressing the same problem at each session. Each task reveals a different aspect of the self. It is the repetition of this goal that reveals the truth.

Today’s art therapists have evolved into a complex body of clinicians working in an array of settings. The roots of art therapy began with the introduction of art into the regimen of patients in hospitals, nursing homes, and other institutions that served a wide range of populations. These early programs were activity projects run by volunteers and provided patients with an opportunity for socialization in the facility. They served also for staff to observe the patient’s ability to function physically and mentally. The connection from the art to any value or use other than participation was never explored.

The introduction of the use of art as a therapeutic tool was defined in Margaret Naumburg’s Dynamically Oriented Art Therapy: Its Principles and Practice (1987). She writes:

The process of dynamically oriented art therapy is based on the recognition that man’s fundamental thoughts and feelings are derived from the unconscious and often reach expression in images rather than in words. By means of pictorial projection, art therapy encourages a method of symbolic communication between patient and therapist. Its images may, as in psychoanalytic procedures, also deal with the data of dreams, phantasies, daydreams, fears, conflicts and childhood memories. The techniques of art therapy are based on the knowledge that every individual, whether trained or untrained in art, has a latent capacity to project his inner conflicts into visual form. As patients picture such inner experiences, they frequently become more verbally articulate. (p. 1)

Naumburg expands on how verbalization may affect the progress of treatment:

Art therapy is not opposed to verbalization, which it uses in combination with spontaneous art production, but it has been shown that patients become able to associate freely in words to the spontaneous images they have created, and this leads inevitably to a speeding up of the therapeutic process. (pp. 3–4)

Though many approaches were based on Naumburg’s original work and developed into structured academic programs, others that followed became the product of particular art therapists whose practice was defined by the different populations they served.

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Like the medical profession, which no longer offers a general internist, once known as the family doctor who made house calls, art therapy is now multidimensional in its scope. It serves a wide variety of individuals including patients who are not hospitalized and who range from very young children to the aged and dying. Art therapists have adapted to situations of crisis, serving as special counselors in emergency situations to individuals and groups. Trained and credentialed, art therapists have not been welcomed by the therapeutic community. Artists are not viewed as disciplined, hardworking, or focused. A reticence by other therapists to accept art therapy as a legitimate discipline may stem from a feeling that art therapy is not traditional enough to trust. It is hoped that this text will dispel that fear and encourage other clinicians to embrace its methods.

This book is designed to be used by all professionally trained clinicians. It invites them to open their creative corridors to apply a new approach to treatment of addictive disorders. The work is dedicated to the idea that all therapists are connected to each other. Therapists who use mainly verbal treatment have nonverbal components present in their work. The ambience of their office, their own appearance and manner, the arrangement of time, are all nonverbally present in the session; the verbal therapist is impacted in turn by the appearance, manner, and participation in the session of the patient. All the nonverbal elements factor into a process that is mainly verbal.

In much the same manner, the art therapist is impacted verbally in important ways during a session that is mainly focused on the nonverbal, i.e., drawing, clay work, weighing and measuring the body. All these are accompanied by the intervention of important verbal exchanges. The ability of the patient involved in art therapy to express herself in words is vital to her ability to participate in her life. The two parts must be developed together. The reader will see how this is accomplished in the application of the tasks (see chapter 4). Right and left brain hemisphere activity is the key to illumination, healing, and growth.

CHAPTER 1

Significance of Appropriate Body Image

———  Art Therapy in the Twenty-first Century

This book explores the use of phenomenal and nonphenomenal body image tasks as therapeutic treatment in anorexia nervosa and obesity. Treatment measures for these syndromes have been major topics of theory and research in recent years as these and other eating disorders have increased in frequency and even impacted on young children. There has been general failure to find lasting solutions to management of these intractable conditions, which have a high rate of morbidity and mortality (Weiner 1985).

The author’s interest in these concepts developed while working with groups of chronic alcoholic and drug-abused patients as well as those with eating disorders. The clinical evidence was compelling in identifying an addictive quality common to these various problems. Hatterer (1980) addresses this idea:

I do not believe that any one addictive personality type exists, but that people become addicted because they are vulnerable to the addictive process, which is rampant in our culture…. Today we extend the concept of addiction … not only to drugs or alcohol, but to food, smoking, gambling, buying, or some form of work, play or sex. I believe that all these addictions have a common denominator, which is a process that depends on constitutional, family, peer, environmental, and sometimes genetic, physiologic, chemical and ethnic factors, and which serve one or several functions in a person’s adaptation to life. (pp. 15–16)

Hatterer’s concept that the abuse of food may be a function of the addictive process is supported by studies by Dole at Rockefeller University. He observed that the tendency of obese patients to relapse after dieting resembled the tendency of cigarette smokers and heroin addicts to relapse even after long periods of abstinence. He concluded that relapses among some obese patients have a metabolic biochemical origin.

Hatterer’s and Dole’s view of eating disorders as addictive in quality is borne out by the work of Marrazzi and Luby (1986). They state, "Endogenous opioids may play a homeostatic role in appetite regulation in humans at both ends of the spectrum (pp. 193–194). They conclude:

Chronic anorexia seems unresponsive to the spectrum of psychotherapies. Current psychological hypotheses … are of limited utility in reversing its course when it has stubbornly persisted for years…. An auto-addiction model may not only provide a basis for further biological research but contribute to alternative therapeutic approaches as well. (p. 202)

This work is focused on the method used with individuals who have suffered with eating disorders. Chapter 5 details the case studies of five women, two anorectic and three obese, who completed the protocol described in chapter 4. Chapter 4, Phenomenal and Nonphenomenal Body Image Tasks in the Treatment of Eating Disorders (PNBIT): The Method, is presented in the form of a manual for the use of a therapist working with individuals who are affected with these syndromes. The PNBIT can be used by a therapist who works primarily with verbal means. Where the therapy appears to be static, the application of some or all of the tasks can move the patient/client toward self-management, healing, and growth.

Following are some definitions of terms used in the text:

—— Body image: The picture of our own body that we form in our minds (Schilder 1953). Bruch (1973) defines it as a plastic concept which is built from all sensory and psychic experiences and is constantly integrated in the central nervous system. Underlying it is the concept of Gestalt, which sees life and personality as a whole (p. 87).

—— Combined phenomenal and nonphenomenal task: Body Contour Drawing (BCD). See chapter 4.

—— Nonphenomenal body image: A term used to denote the individual’s unconscious and symbolic expression of the self acquired over time through interpersonal relationships.

—— Nonphenomenal tasks: 1. Chromatic Family Line Drawing (CFLD), 2. House/ Tree/Person/Person/Animal (HTPPA), pencil and chromatic, 3. Mandalas (M), Body Image and Self Image, 4. Sandworlds (SW), 5. Self Box (SB), 6. Kinetic Family Clay Sculpture (KFCS).

—— Normal weight: A term used to denote weight in pounds plus or minus five percent of the normative weight for age and height as designated in current medical weight table.

—— Phenomenal body image: A term used to denote the individual’s direct and conscious awareness of the body as an objective physical entity, based on sensory experiences, involving sight and touch, focusing on weight, form, mass, coloring, and measurements of length and breadth of the body boundaries.

—— Phenomenal tasks: 1. Weighing of individual on scale, 2. self-viewing in full-length mirror, 3. self-analysis through touch and other sensory input, 4. Body Dimension Estimates and Measurements (BDEM).

—— PNBIT: Phenomenal and nonphenomenal body image tasks, i.e., the group of eleven items administered to the individuals in chapter 5. (For a complete description of tasks see chapter 4.)

—— Self: The psychophysical total of the person at any given moment, including both conscious and unconscious attributes (Hinsie and Campbell 1970).

—— Self-concept: The whole range of complicated attitudes and fantasies an individual has about her identity, her life role, and her appearance. This is in contradistinction to attitudes an individual expresses about herself verbally. It is assumed some of the most important of the individual’s self-concepts are either so unpleasant to face or are acquired at such an early preverbal period as to be unavailable for conscious reporting (Fisher and Cleveland 1968).

—— Self-esteem: The appraisal or value the individual sets on the self.

—— TSCS: Tennessee (Department of Mental Health) Self Concept Scale, a pencil and paper verbal measure of self-concept. The scale consists of one hundred self-descriptive statements the subject uses to produce a verbal picture of herself.

—— Yo-yo syndrome: Chronic condition affecting an individual which manifests itself in episodes of alternative bingeing and dieting as a means of gaining and losing weight.

There is no way to understand how art therapy works without connecting it to the making of art. The search for meaningful form is one of the primary goals in psychotherapy.

Persons in analysis … are struggling with their world—to make sense out of nonsense, meaning out of chaos, coherence out of conflict. They are doing it by imagination, by constructing new forms and relationships in their world, and by achieving through proportion and perspective a world in which they can survive and live with some meaning. (May 1975:125)

If a nonhealth or pathological state is defined as having the quality of disturbance or disorder in one’s life, then a state of health may be defined as that which moves toward ordered form. Rogers said, Man’s behavior is exquisitely rational, moving with subtle and ordered complexity toward the goals his organism is endeavoring to achieve (1961:194–195). This idea is emphasized by May (1975):

Our passion for form expresses our yearning to make the world adequate to our needs and desires, and, more important, to experience ourselves as having significance…. Insights emerge not chiefly because they are intellectually true or even because they are helpful, but because they have a certain form, the form that is beautiful because it completes what is incomplete in us…. This new form that suddenly presents itself, comes in order to complete a hitherto incomplete Gestalt with which we are struggling in conscious awareness. (p. 132)

Such a process involves organismically selected direction that allows psychological freedom within prescribed limits set by the inner and outer environments of each individual. One may see a parallel here from psychological form to art form. Writing in 1913, Bell (1958), the English critical theoretician of art, revolutionized the study of all the arts by his concept of form:

For either all works of visual art have some common quality, or when we speak of works of art we gibber…. What is this quality? … Only one answer seems possible—significant form. In each, lines and colours combined in a particular way, certain forms and relations of forms, stir our aesthetic emotions. (p. 17)

He continues, These relations and combinations of lines and colours, these aesthetically moving forms, I call ‘significant form’ and Significant Form is the one quality common to all works of art (p. 18).

Langer (1957) reevaluated and expanded on Bell’s original concept:

Artistic form is congruent with the dynamic forms of our direct sensuous, mental, and emotional life; works of art are projections of felt life, as Henry James called it…. A work of art expresses a conception of life, emotion, inward reality…. It is a developed metaphor, a nondiscursive symbol that articulates what is verbally ineffable—the logic of consciousness itself. (pp. 25–26)

She continues:

A work of art is an expressive form created for our perception through sense or imagination, and what it expresses is human feeling…. One quality shared by all good works of art is significant form … structure, articulation, a whole resulting from the relation of mutually dependent factors or more