Dance/movement Therapy and Bulimia Nervosa

REPAIRING THE BROKEN MIRROR: A THEORETICAL DANCE/MOVEMENT
THERAPY MANUAL FOR THE TREATMENT OF WOMEN WITH BULIMIA
by
Ariele L. Riboh
© 2009 Ariele L. Riboh
A thesis
submitted in partial fulfillment
of the requirements for
the degree of Master of Science
(Dance/Movement Therapy)
School of Art and Design
Pratt Institute
October 2009  
Repairing the Broken Mirror ii
REPAIRING THE BROKEN MIRROR: A THEORETICAL DANCE/MOVEMENT
THERAPY MANUAL FOR THE TREATMENT OF WOMEN WITH BULIMIA
by
Ariele L. Riboh
Received and approved:
______________________________________ Date _____________________

Thesis advisor -Valerie Hubbs, MS, ADTR, NCC, CGP, LCAT, LMHC
______________________________________ Date _____________________

Chairperson—Jean Davis, MPS, ATR-BC, LCAT
Repairing the Broken Mirror iii
TABLE OF CONTENTS
LIST OF TABLES………………………………………………………………………...v
ABSTRACT……………………………………………………………………………...vi
Chapter
1. Introduction………………………………………………………………………..1
History of Eating Disorders

Defining Eating Disorders
Medical Etiology
Psychological Etiology
The Mother-Infant Relationship
Mismatches and Impingements
Trauma
Role of the Media and Body Care Industry
Dance/Movement Therapy Treatments
2. Methodology……………………………………………………………………..32
Rationale
Apparatus
Participants
Procedure
Data Collection and Analysis
3. Results……………………………………………………………………………37
DMT Theoretical Practices

Treatment Themes and Goals
Movement Characteristics
Movement Interventions
Transference and Countertransference
Therapist’s Self-Care
Repairing the Broken Mirror iv
4. Discussion………………………………………………………………………..48
Findings
Literature review
Questionnaire
Significant Findings and Recommendations
Need for collaboration
Need for Further Clarification and Exploration
Validity and reliability
Conception of movement patterns
Utilization of specific interventions
Monitoring DMT effectiveness
Therapist self-care
Study Limitations
REFERENCES………………………………………………………………………56
Appendixes…………………………………………………………………………..61
Manual…………………………………………………………………………...pocket
  
Repairing the Broken Mirror v
List of Tables
Table E1. Answers to Questionnaire Concerning DMT Experience of Participants.

Repairing the Broken Mirror vi
Abstract
Today eating disorders, in particular bulimia nervosa, are rising at an alarming rate
despite the current available treatments. Due to the somatic nature of this illness,
dance/movement therapy appears to be an appropriate and perhaps more relevant
therapeutic modality. In order to investigate this, a case study examining the work of four
dance/movement therapists working with women suffering from bulimia nervosa (BN)
was conducted. Factors examined included: themes emerging for patients in treatment;
movement characteristics; specific movement interventions; the therapist’s use of
transference and countertransference, and the self-care methods used by dance/movement
therapists. It seems that there are commonalities among women suffering from BN, such
as issues surrounding self-esteem and a sense of self. There also appears to be themes that
emerge in treatment that are characteristic of this population, such as shame and control.
Despite similar characteristics in certain areas, there was significant disagreement when it
came to the actual practice of dance/movement therapy (DMT).

Repairing the Broken Mirror 1
Repairing the Broken Mirror: A Theoretical Dance Movement Therapy Manual for the
Treatment of Women with Bulimia.
Today, the incidence of eating disorders is reaching concerning levels. According
to the National Institute of Mental Health (as cited in Eggers & Liebers, 2007), “0.5 to
3.7 percent of women develop anorexia nervosa and some 1.1 to 4.2 percent experience
bulimia nervosa (BN) in their life time” (p. 2). In addition to these troubling percentages
it appears that, despite treatment efforts, the prevalence of eating disorders continues to
increase in our Western society. According to the National Eating Disorder Association
(2006), the incidence of bulimia in the USA has tripled for women ages 10-39 between
1988 and 1993.
Many approaches have been used for the treatment of people with eating
disorders, including psychodynamic, action-oriented, cognitive-behavioral, interpersonal,
self-psychology, structural family therapy, developmental, feminist, pharmacological,
group and individual therapy, and short- and long-term therapy (Krantz, 1999, p. 83).
Studies with promising results have been conducted on the short-term effectiveness of
cognitive behavioral therapy and on interpersonal therapy. Yet, there are few studies that
show efficacy in the long-term treatment of this population. Although many modes of
treatment for eating disorders are currently in place, the recovery rates are relatively low
among patients receiving treatment with approximately 30% of full recovery for people
with anorexia and 50% for people with bulimia nervosa. In an effort to contribute
towards a more holistic and effective treatment of bulimia nervosa in women, the current
study aims towards the compilation of a pilot treatment manual presenting
dance/movement therapy (DMT) as primary modality for the treatment of women with
BN.
History of Eating Disorders
Eating disorders are not new phenomena, and have been documented within
psychiatric literature since the 17th century. At that time, they were known as a nervous
disease or hysteria (Maine, 2009, p. 6). Different hypotheses regarding BN etiology have
since been explored.
Freud originally attributed eating disorders to “neurotic conflicts about sexuality”
(Maine, 2009, p. 7) he viewed these conflicts as involving “oral incorporative
mechanisms and oedipal genital wishes” (Schneider, 1995, ¶ 4). Schneider (1995)
suggests that Freud attributed the purging involved in bulimia nervosa to the following:
. . . [an underlying] oral sadistic, cannibalistic, sexual fantasy. This fantasy was
that, from the young, eating-disordered girl’s point of view, she could eat the
father’s penis and be impregnated with his baby (Freud, 1905/1953). Psychogenic
vomiting was the girl’s neurotic, hysterical symptom resulting from this
unconscious sexual conflict and subsequent compromise formation. (¶ 4)
In the 1960s, behavioral treatment emerged as the popular choice of treatment.
Today, according to Vanderlinden (2008), cognitive behavioral therapy (CBT) remains
the treatment of choice and is highly recommended by most “evidence-based treatment
guidelines” (p. 329). As Vanderlinden explains, the CBT approach suggests that a
“dysfunctional scheme of evaluation” (p. 329) is central to the maintenance of eating
disorders. This signifies that most people suffering from eating disorders present
unrealistic beliefs about their bodies and weight. CBT treatment is thus believed to target
these dysfunctional beliefs directly.
It was not until Hilde Bruch’s assessment of eating disorders in the 1970s, that
their origins were viewed as both biological and psychological. Bruch (as cited in
Schneider, 1995), in opposition with Freud, attributed eating disorders to issues that arose
during the separation-individuation process. She believed that eating disorders were an
unconscious struggle between the wish to be separate and the wish to remain one with the
mother figure.
Anorexia nervosa was the first identified eating disorder and the mental illness
now known as bulimia nervosa was initially seen as a subset of anorexia. In 1976,
Boskind-Lodahl identified a disorder known as bulimarexia, but it was not until 1979
with Russell that bulimia nervosa was named and differentiated as a separate disorder
(Maine, 2009, p. 7). Many studies have continued to explore the causes of eating
disorders linking their origin to primary biological abnormalities, gastrointestinal
problems, disruptions of various cerebral components, an inability to negotiate critical
developmental stages, cultural and societal influences, and several other causes.
A number of studies have investigated the etiology of these disorders, yet there is
much discordance in the findings and a notable lack in longitudinal studies. Waller and
Sheffield (2008) claimed that studies have had “a tendency to investigate factors in
isolation . . . [and that they] focus on diagnostically pure groups which fail to reflect [real
life] clinical populations” (p. 152). A significant amount of research has been done to
investigate the phenomenology of eating disorders and many plausible hypotheses have
been put forward. However, none have lead to significant scientific data serving to either
confirm or deny the etiology of eating disorders. In a recent report, the U.S. Department
of Health and Human Services (as cited in Maine, Davis, & Shure, 2009) “lamented the
lack of reliable, clinically relevant empirical findings and emphasized the importance of
more qualitative studies to broaden the base of available treatment information and
expertise” (p. i). It is thus necessary to further understand the lack of reliability of current
studies and explore alternative options for the effective treatment of eating disorders.
Many risk factors are thought to be associated with this mental illness, including
genetics, family experiences, traumatic experiences, as well as a host of other factors that
can be attributed to environmental and socio-cultural influences. However, specific
responsible factors have yet to be determined.
According to Krantz (1999), “Eating disorders refer to disturbances of eating
behaviors and body-image distortions with underlying psychodynamic, cultural, and
gender conflicts” (p. 82). It is essential to identify a clear definition of eating disorders in
order to understand the implications of their complex etiologies and their effects on
treatment options.
Defining Eating Disorders
According to Davis (2009), eating disorders are primarily psychological disorders
as, “food and eating are symbolized or given meaning beyond ordinary nourishment and
consumption and because, as food and eating is symbolized, a variety of medical,
psychological and social problems are created” (p. 36). Anorexia nervosa is primarily
characterized by the refusal to eat and by a low body weight accompanied by significant
body-distortion. The main symptoms of BN are recurrent episodes of binging and

purging by self-induced vomiting, abuse of laxatives, and vigorous exercise (Krantz,
1999, p. 82).
According to the American Psychiatric Association Diagnostic and Statistical
Manual of Mental Disorders (2000) text revision, eating disorders are “severe
disturbances in eating behaviors” (p. 583), and anorexia nervosa is defined as “a refusal
to maintain a minimally normal body weight” (p. 583). Anorexia is divided into two
subtypes: restrictive and binge-eating/purging type. The anorexic person is said to fear
the thought of gaining weight or becoming fat and is subject to significant body image
distortion (p. 583). This fear is not alleviated by weight loss and one often utilizes drastic
measures such as minimal caloric intake, frequent mirror checking, and repetitive weigh-
ins in an attempt to alleviate subsequent anxieties. This weight loss is often dramatic and
represents a health hazard that can lead to death. Weight loss appears to give the person
with anorexia a sense of self-control and any weight gain is seen as a dramatic failure (p.
584). Several physical side effects, such as amenorrhea and the growth of lanugo, a form
of peach-like hair all over the body, are present as diagnostic features. There are also
psychological symptoms that accompany this illness which are thought to be a result of
starvation. Such symptoms may be expressed as “depressed mood, social withdrawal,
irritability, insomnia and diminished interest in sex” (DSM-IV-TR, 2000, p. 585).
Obsessive-compulsive features, such as “preoccupied thoughts of food” (p. 585) and rigid
thinking, have also been identified as symptoms.
According to the DSM-IV-TR (2000) text revision, bulimia nervosa is defined as,
“repeated episodes of binge eating followed by inappropriate compensatory behaviors”
(p. 583). A binge is defined as, “eating in a discrete period of time an amount of food that
is definitely larger than most individuals would eat under similar conditions” (p. 589).
Bulimia nervosa is also divided into purging and non-purging types. However, the two
are very similar in their psychological development and symptomology. Binging
behavior is characteristically done in secrecy and is associated with intense feelings of
shame and guilt. The DSM-IV-TR (2000) text revision states that binging is “typically
triggered by dysphoric mood states, interpersonal stressors, intense hunger following
dietary restraint, or feelings related to body weight, body shape and food” (p. 590). This
behavior is utilized as a means of self-regulation and provides temporary relief for the
person. It is thought that often during these phases of binge and purge the person enters
into a dissociative state that is subsequently felt as an utter loss of control. In order to
compensate for this loss of control, many engage in compensatory behaviors known as
purging. The most common means of purging is by self-induced vomiting. Some 80% to
90 % of people with bulimia adopt this method of purging. Other disordered behaviors
are also used to compensate for binging behavior and to prevent weight gain. Such
behaviors include abuse of laxatives and diuretics, excessive exercise, fasting between
binges, and so forth. Associated with this symptomology, people suffering from bulimia
nervosa often suffer from depressed mood states and present symptoms fulfilling the
criteria for mood disorders, anxiety disorders, and personality disorders.
The DSM-IV-TR (2000) text revision also offers a definition for eating disorder
Not Otherwise Specified (NOS) among this diagnostic category. This category is utilized
for diagnosing all other eating disordered behaviors that do not fall under the criteria for
either anorexia or bulimia. Further diagnostic criteria and a detailed description of this
category can be found in the DSM-IV-TR (2000) text revision (p. 592), or in the desk
reference to the DSM-IV-TR (2000) text revision (p. 265). Considering the complexity
and expansiveness of each separate diagnosis, it is beyond the scope of this study to
examine each diagnostic category in depth. The current study will focus solely on the
diagnosis of bulimia nervosa. Also, due to the overwhelming 90% incidence of this
eating disorder among women (Maine et al., 2009, p. xxii), the current study will solely
focus on the female population.
Now that a preliminary understanding of the symptomology of this disorder has
been presented, it is important to present the origins of this illness in order to better serve
potential BN patients.
Medical Etiology
Eating disorders are complex disorders that affect individuals not only mentally,
but also physically. According to Kaye (2008), eating disorders are currently of unknown
etiology; however, there is “growing acknowledgement that neurobiological
vulnerabilities make a substantial contribution to the pathogenesis of anorexia nervosa
and bulimia nervosa” (p. 121). These findings are not yet fully understood and more
studies are needed to further clarify the matter. Some researchers have attributed
neurological disturbances associated with eating disorders to neuropeptide dysregulation.
Neuropeptides are molecules involved in message transmission by neurons in the
brain/body communication process. Hence, neuropeptide dysregulation can directly affect
brain activity and body physiology (Kaye, 2008). For example, essential hormonal
activity, such as gonadal, thyroid, and so forth could be affected. However, it appears that
the disturbance of neuropeptides might be in itself the result of the eating disorder. Kaye
has noted that there are various hypotheses investigating the roles of monoamine neurons,
tying abnormal levels of serotonin (5-HT), an essential neurotransmitter, to “appetite
dysregulation, anxious and obsessional behaviors and extremes of impulse control” (p.
124). This disturbance of serotonin level appears in parallel to the disorder and seems to
persist after recovery.
Twin studies on eating disorders have also been conducted and results suggest
that there is possibly a biological nature to these disorders. According to Kaye (2008):
There is approximately a 50 to 80% genetic contribution to liability accounted for
by additive genetic factors. These heritability estimates are similar to those found
in schizophrenia and bipolar disorder, suggesting that anorexia nervosa and
bulimia nervosa may be as influenced as disorders traditionally viewed as
biological in nature. (p. 122)
Also, with the advance of technology, recent research using brain-imaging techniques,
such as computerized tomography (CT) and magnetic resonance imaging (MRI), has
contributed to the emergence of new hypotheses about brain abnormalities in individuals
with eating disorders (Kaye, 2008). Although sample sizes and the number of studies are
limited, “differences in ill and recovered eating disordered individuals in frontal,
cingulated, temporal, and/or parietal regions compared to controls” have been observed
(Kaye, 2008, p. 125). Brain imaging studies have also shown elements such as atrophied
areas, enlarged ventricles, deficits in both grey and white matter, and decreased cortical
mass for individuals suffering from eating disorders (Kaye, 2008). Some of these
elements appear to normalize themselves with recovery from eating disorders, but again
these findings remain in their preliminary stages because of the lack of longitudinal
studies.
Psychological Etiology
Having explored various medical hypotheses, it is important to explore other
models and schools of thought to fully understand the many components of this illness.
The following is an examination of the symptomology for bulimia established by the
Psychodynamic Diagnostic Manual (PDM) (2006).
According to the PDM (2006), depression, social isolation, low self-esteem,
anxiety, and loss of libido appear to be some of the predominant issues that arise for these
patients. Panoply of symptoms, feelings, and affective states can be linked to bulimia
nervosa. Common feelings that can accompany these affective states are “feelings of
being starved for care and affection” (PDM Task Force, 2006, p. 120), feelings of failure,
shame, anger, aggression, and loss of control.
The PDM (2006) advances the hypothesis that these emotions and affective states
emerge from cognitive patterns that have been established in the individual’s childhood.
Psychodynamic theoreticians also hypothesize that many of these affective states and
associated feelings and emotions emerge not only psychologically, but also somatically.
These somatic states seem to be frequently expressed as feelings of numbness and of
disconnection from or confusion about the body. Another area that appears to be
problematic for this population is that of relational patterns. Social isolation and difficulty
forming relationships are typically present. The PDM indicates that among these patterns,
issues around control, perfectionism, and secrecy emerge significantly. Indeed, the PDM
advances relevant hypotheses as to the etiology of bulimia and illustrates some of the
main characteristics of this population. These are essential elements for the current study,
as they will aid in better understanding individuals suffering from eating disorders, hence
allowing for more comprehensive and adaptive treatment plans.
The Mother-Infant Relationship
From psychodynamic, self-psychology, and object relations perspectives, the
origins of eating disorders can be traced back to infancy. These approaches emphasize the
importance of the mother-infant relationship for the future psychological development of
the infant. From birth, an infant begins to learn about the world through the eyes and
body of the mother/caregiver. It is through this attachment that an interpersonal
relationship is formed between mother and infant and allows for the “immature brain [to]
use the mature functions of the parent’s brain to organize its own processes” (Siegel,
1999, p. 67). Through these processes, the child begins to learn modulation of positive
and negative feelings, forming the basis for the capacity to self-regulate. It is through the
formation of an adequate attachment between a mother and her infant that the infant is
able to establish and feel a sense of internal safety and emotional security which is “a
reflection of confidence in the availability of attachment figures”, which lead to a secure
attachment (Mitchell & Black, 1995, p. 136). The opposite is known as an insecure
attachment, which “may serve as a significant risk factor in the development of
psychopathology” (Mitchell & Black, 1995, p. 68).
It is also through the mother-infant relationship that the elements of merging and
differentiation come into play. Merging occurs when the infant and the mother’s internal
rhythms are synched and in tune with one another. Merging allows for the occurrence of
symbiosis and attunement, two essential elements in the creation of a secure attachment.
“Attunement involves the alignment of states of mind in moments of engagement during

which affect is communicated with facial expression, vocalizations, body gestures, and
eye contact” (Siegel, 1999, p. 88). Through differentiation, which naturally results from
merging, the infant is able to develop a sense of identification, leading to the future
development of the self. Consequently, the self is developed “through the ongoing
process of identification with (or . . . merging) and differentiation between internalized
images of one’s own self and those of external objects-real objects or persons” (Pallaro,
1996, p. 113). This pattern of merging and differentiating, once internalized, will be the
basis of engagement for future relationships.
The role of the mother-infant relationship is also essential in the physical and
neurological development of the infant.
These relationships are crucial in organizing not only ongoing experience, but the
neuronal growth of the developing brain. In other words, these salient emotional
relationships have a direct effect on the development of the domains of mental
functioning that serve as our conceptual anchor points: memory, narrative,
emotion, representations, and states of mind. In this way, attachment relationships
may serve to create the central foundation from which the mind develops. (Siegel,
1999. p. 68)
The subjective experience of the infant as lived through the body is also of utmost
importance, as it is “the crucial and principal organizer of object representations in
infancy” (Pallaro, 1996, p. 114). Indeed, the infant begins with the identification of the
self as subject and it is through interaction with the parents and the family of origin that
the infant begins to develop a sense of self as an individualistic entity.

As important as the mother/caregiver is for the psychological development of the
infant, one must not forget the importance of touch and physical contact between the
mother and the infant. Renee Spitz (as cited in Mitchell & Black, 1995), one of the first to
explore the significance of touch, studied children in orphanages whose basic needs were
met, but who were deprived of nurturance. He found that, after 3 months in these
conditions, the infants demonstrated reduced eye contact and appeared withdrawn and
depressed. By age 2, some had died and others were considered to be nonfunctional.
Referring to what he found as failure to thrive, Spitz explained that this phenomenon was
due to the lack of touch and adequate nurturance. Harry Harlow further explored the
importance of touch through experiments with baby rhesus monkeys that were separated
from their mothers. In Harlow’s experiment, the monkeys were provided two surrogate
mothers, one that was a wire doll with a bottle for feeding and one that was covered in a
soft material and was heated. The babies fed from the wire doll but immediately went to
the cloth doll for nurturance (Orbach, 2009, p. 47-8). Through this study, “[Harlow]
demonstrated that a sense of touch and warmth were crucial for bonding” (Orbach, 2009,
p. 47). These studies have been essential for understanding where elements of trauma and
impingement can occur in infancy. These may help formulate tailored interventions,
which can compensate for and help overcome deficiencies that potentially contribute to
eating disordered symptomatology.
It is also through the repeated and consistent contact with the mother’s body and
through the awareness of its own bodily sensations that the “infant develops its own
boundaries, as delimiting and containing a personal sense of self” (Pallaro, 1996, p. 114).
According to Orbach (2009):

Every aspect of our body sense embodies something about our mother’s own
physicality. If she is awkward and physically reticent, we pick that up. If she is
bold or intrusive, our personal body sense will accommodate that in some form. If
she fails to touch us in a firm yet gentle manner, we may become confused or
fearful about our bodily sensations. We might not know where our body begins
and where it ends. (Orbach, 2009, p. 50)
It can therefore be postulated that the skin represents the body’s boundary for the
self. It is consequently this physical boundary that allows for differentiation between
internal and external. This knowledge is of great importance, as women with bulimia
nervosa often struggle with elements of self-differentiation.
Mismatches and Impingement
Having explored the different ways in which the role of the mother-infant
relationship affects infant development, it seems clear that this critical relationship affects
not only the immediate experience of the infant and the satisfaction of his or her most
primitive needs, but that it also serves in the normal development of the self and of body
boundaries. Consequently these elements lay the groundwork for future relational
patterns, which fall into the different attachment categories established by Ainsworth.
These relational patterns consist of secure, anxious/avoidant, anxious/resistant (Tracy &
Ainsworth, 1981, p. 1341) or secure, avoidant, ambivalent and disorganized/disoriented
(Mitchell & Black, 1995). Ainsworth’s strange situation was a test done to investigate the
different types of mother-infant attachments. This study was conducted in a controlled
setting consisting of a playroom with a one-way mirror from which the researchers
observed. The actual study consisted of observing the interactions of a mother and her
infant and the reactions of the child following the introduction of a stranger with and
without the mother present. A securely attached child is reportedly able to explore and
engage with strangers while the mother is present. However he/she will become
distressed upon the mother’s departure and will cease to engage with the stranger. The
infant is soothed and reassured upon the return of the mother. The anxious/avoidant
either avoids or ignores the mother and shows little emotion upon the departure or return
of the mother. Engagement with the stranger is similar to with the mother.
Anxious/ambivalent behavior is characterized by the infant demonstrating a significant
amount of anxiety around strangers even with the mother present. Upon departure of the
mother, the child is extremely distressed and when she returns the infant demonstrates
mixed emotions, where he/she might seek proximity but at the same time might attempt
to hit or push the mother. The last category, disorganized/disoriented, was an addition to
Ainsworth’s work. In this case the child becomes distress when the mother departs but
avoids and ignores her upon her return. The child might also demonstrate odd behaviors
such as freezing or falling to the floor upon the mother’s return (Wikipedia online
encyclopedia).
As seen above, the mother-infant relationship can be a subtle and quite intricate
one, and even when a mother is striving to be what Winnicott termed, the good enough
mother, “mismatches” (Stern, 1977, p. 140) can occur. These mismatches occur when
there are regulatory failures due to overstimulation, understimulation, or paradoxical
stimulation.
Overstimulation is often the result of a caregiver who is controlling and intrusive,
which in turn interferes with the infant’s ability to self-regulate. As a result of these
behaviors, the infant “may then be forced to develop more extreme regulating or
terminating behaviors” (Stern, 1977, p. 140). This overstimulation by the caretaker also
sends the message to the infant that he or she cannot regulate his or her external world or
internal experiences through emotional communications. If this behavior of
overstimulation is chronic, the infant will progressively display inhibited motor
expression and affective facial expressions.
If a mother is depressed, schizophrenic, inhibited due to character pathology or
has a limited repertoire of social behaviors, under-stimulation of the infant can occur.
Further, if the infant “is hypoactive or has a significant developmental lag or minimal
brain damage, then a normally effective amount of stimulation may not move him up to
or keep him within the optimal range” (Stern, 1977, p. 148) and under-stimulation may
be the result.
Mothers who respond appropriately to their infants only in the case of danger or
distress are examples of paradoxical stimulation. These caregivers are often referred to as
neglectful or abusive. Indeed, such caregivers only become animated when the infant
who has a “‘repertoire’ of common self-hurtful or discomforting mishaps [displays these
behaviors]. . . . Many of these mishaps are funny in the way that slapstick is funny, and
most caregivers may laugh (if there is no real injury)” (Stern, 1977, p. 149). However the
paradigm that is learned by the infant in these instances is that of masochism, or “pain as
the condition for pleasure” (Stern, 1977, p. 150). Another form of paradoxical stimulation
is that of the “mutual approach-withdrawal dance” (Stern, 1977, p. 150). This form of
stimulation can lead to difficulties during the negotiation of separation-individuation.

These types of interactions with the mother form the basis for later relational
patterns of the infant. If, indeed, these are troublesome and inadequate, they can lead to
difficulties in social interactions and relationships, which appear to be characteristic of
many women with bulimia.
Separation-individuation is a model of infant development established by
Margaret Mahler (Mitchell & Black, 1995, p. 43). This model reinstates the role of the
caregiver as capital for the future psychological development of the child. The process of
separation-individuation is divided into three sub-phases. The first is hatching, which
takes place from 0 to 9 months. During this phase, the infant demonstrates “increased
alertness” (Mitchell & Black, 1995, p. 46), a more outwardly directed gaze that is used to
check back with the mother/caregiver as a point of reference. Following this, is the sub-
phase of practicing, where the toddler is “infused with a sense of omnipotence: despite
actual moving away from his mother, he experiences himself, physically, as still one with
her, sharing in her perceived omnipotence” (Mitchell & Black, 1995, p. 47). Finally, from
15 to 24 months, the child reaches the sub-phase of rapprochement in which the child
undergoes “physic disequilibrium” (Mitchell & Black, 1995, p. 47). This disequilibrium
is experienced as the realization of the physical and mental separation that begins to
occur. The once fearless toddler begins to lose his or her previous sense of omnipotence
and fear begins to settle in. The constant desire for proximity with the mother reappears.
During development, all of these sub-phases are essential as they contribute to the
development of the child’s ego and ability to self-regulate. Newton (2005), further notes
that if the mother/caregiver is not emotionally and physically available, the infant is
susceptible to ego deficiencies and disturbances. These deficiencies and disturbances can
lead to poor ego strength, which can manifest itself in many forms, such as poor coping
mechanisms including difficulty coping with stress. These appear to be issues
encountered in the bulimic population. Newton postulated that:
If this was not experienced psychological ego development may become
vulnerable to self-pathology, with disturbances in internal and external object
representations corresponding to sub-phases in separation and individuation. Pine
(1979) articulates two adult self-pathological manifestations. A “lower order”
disturbance is marked by an uncertain self and other boundaries, leading to a loss
of self. A “higher order” disturbance is distinguished by an inability to tolerate
aloneness, by attempts to reestablish coercive omnipotent control over external
objects, and by object constancy deficits. (p. 173)
As a result of these mismatches, impingements, and lack of consistent nurturance, the
infant can develop a sense that there is something “not quite right” (Orbach, 2009, p. 81)
with him or her. In consequence to this feeling of inadequacy, the infant develops a
misconstrued sense of self. Orbach saw this as the grounds for the development of a false
self.
There are numerous ways in which the mother/caregiver and the infant develop a
relationship. Ultimately, one hopes that a caregiver will be able to encompass the
qualities of Winnicott’s concept of good enough mother, which provides optimal levels
of frustration tolerance and nurturance, and which avoids impingement (Mitchell &
Black, 1995, p. 129). Impingement occurs when the mother fails the child by “allowing
external stimulation to reach painful levels, by intruding into the base state of drifting
quiescence, or by allowing the child’s internal needs to build to frustrating levels”

(Mitchell & Black, 1995, p. 209). In other words, impingement can be understood as the
failure of the mother “to protect the delicate state necessary for psychological growth and
health” (Mitchell & Black, 1995, p. 209).
Unfortunately, there are many interactions possibilities that can lead to what
Beattie (1988) described as:
[a] child with an ego structure inadequate to the tasks of autonomy and self-
regulation, with little capacity to monitor inner bodily states such as hunger and
satiety, and with a resulting tendency to act out conflicts over independence and
self-control via excessive control of the body and its food intake. (p. 453)
This reinforces the idea that to develop a healthy ego and a sense of self, the infant must
be raised in an adequate environment that stimulates normal development.
According to Mahler (as cited in Mitchell & Black, 1995), mental illness is the
direct result of a basic failure of an individual to form a self (p. 41). This failure can be
understood as the non-negotiation of the process of separation-individuation or, more
specifically, the non-negotiation of any given sub-phase of the separation-individuation
process. It is hence fair to hypothesize that eating disorders could possibly emerge from
impingement, poor development of frustration tolerance, inadequate nurturance, or any
combination thereof.
Trauma
Another unfortunate factor that can lead to impingement is trauma, resulting from
physical, verbal, and/or sexual abuse. According to Wonderlich, Brewerton, Jocic,
Dansky, and Abbott (1997), childhood sexual abuse (CSA) is a significant risk factor for
the development of bulimia (p. 1107). Many studies have evaluated the effects of abuse
and its correlation to eating disorders. However, some general inconsistencies are
apparent and it is not clear how exactly childhood abuse “affects the basic symptom of
eating disorders” (Truer et al., 2005, p. 108). Yet, most of the literature agrees that there
is a positive correlation between abuse and bulimia. Leonard et al. (as cited in Brewerton,
2007) conducted a study in which “women with bulimia nervosa reported higher levels of
CSA, childhood physical abuse, and combined childhood sexual/ physical abuse
compared to the non-eating-disordered women” (p. 289).
In summary, genetic predispositions, neurological disturbances, troubles in the
mother-infant relationship and trauma need to be taken into account for the development
of therapy guidelines and dance/movement interventions. In addition to these personal
variables, one needs to acknowledge and understand the influence of external factors
such as the media, and the body-care industry on the development and maintenance of
eating disorders.
Role of the Media and Body care industry
In today’s consumption driven society where instantaneous satisfaction, easy
accessibility to products, competition, permissiveness, women’s stress and forced ideals
dominate, a pervasive marketing emphasis is placed on the body as a commodity. Daily
or even hourly, one is solicited by advertisements, magazines, media events and product
or service offers portraying standards and ways to make our bodies fit into the societal
ideals. “The sense that biology need no longer be destiny is gaining ground, and so it
follows that where there is a (perceived) body problem, a body solution can be found”
(Orbach, 2009, p. 2). Today, beauty no longer appears to be equated with individuality
and variety, but with set standards established by the media and body-care industry.
One’s weight and shape now determines one’s place in society. Beauty and thinness are
associated with power and acceptability. As highlighted by Orbach, “The right body is
trumpeted as a way of belonging in our world today . . . while failing to get one’s food
and size right can signify shame, failure or a rejection of the values we are presumed to
aspire to” (pp. 3, 13).
Consciously or unconsciously the media and body-care industry induce women to
think that they are not good enough if they do not fit within societal norms of the “thin-
ideal” (Grabe, Hyde, & Ward, 2008, p. 461). The images and messages with which we
are regularly bombarded create a sense of shame, and when women fall short, it results
“in a sense of inadequacy” (Shure & Weinstock, as cited in Maine et al., 2009, p. 165).
As a result, women are put in a position where their bodies are the battlefields and they
are shamed for wanting to eat (p. 165). Acceptance and worth become associated with
repression of needs, and deprivation has become common lieu.
According to Grabe et al. (2008), 50% of undergraduate women report being
dissatisfied with their bodies, which is of particular interest, as “research from
prospective and longitudinal designs has identified body dissatisfaction as one of the
most consistent and robust risk factors for eating disorders such as bulimia” (p. 460).
Much research has been conducted examining the correlation between body-image
dissatisfaction, eating disorder symptomology and the influence of the media. According
to Grabe et al., laboratory experiments have been conducted with random samples of
women assigned to view thin-ideal and non-thin-ideal media stimulus. Following
exposure, levels of body dissatisfaction were measured. An overwhelming percentage of
women exposed to thin ideal stimulus reported an increase in body-image dissatisfaction

(p. 461). One may however question these findings and the reliability of these studies as a
large percentage of women are regularly exposed to thin-ideal media, yet, only a fraction
report being dissatisfied with their body image, and an even slimmer fraction develop an
eating disorder. One may hence question the role of the media as either causal or
supportive.
In summary, it is apparent that eating disorders, among which BN, are complex
illnesses associated with a genetic predisposition, external factors such as environment,
the mother-infant relationship, trauma, family dynamics, media, and so forth. These
variables can enable and exacerbate eating disorders. Also, it appears that despite the
availability of current psychiatric, physiological, and behavioral modes of treatment, the
incidence of bulimia continues to rise. Accordingly, dance/movement therapy appears to
be equipped to contribute innovative treatments dealing uniquely with body awareness,
self-expression as well as body-mind integration through a more targeted method of
treatment.
Dance Movement Therapy Treatments
As with any discipline, DMT has evolved since its conception in the 1960’s with
Marian Chace. Although most therapists base their practices on widely acknowledged
concepts and principles that are central to DMT, there is quite a panoply of approaches
that can be used for the treatment of women with BN. To fully understand the application
potential of these options, their review is warranted.
Krueger, a psychiatrist, and Schofield, a dance/movement therapist, have been
working with eating disordered populations for over 20 years. Informed by
developmental theories, they have assumed a “deficit model” (Krueger & Schofield,
1986, p. 325), which hypothesizes that individuals suffering from an eating disorder have
a developmental deficit resulting from an impingement or a frustration, which arose
during critical developmental stages. Stagnation, in Krueger and Schofield’s experience,
appears to have occurred in the following areas: “sense of self, separation-individuation,
somatic recognition and expression with the maturing desomatization to take one’s body
for granted, to live in and through one’s body” (p. 326). This model also hypothesizes
that the mother has failed to acknowledge and confirm a separate body self for the child,
thus leading to a distorted body image and body self.
Building on these hypotheses, Krueger and Schofield (1986) have developed a
therapeutic model targeting these specific variables to ensure a comprehensive treatment
plan. They state that, “a combination of verbal and nonverbal techniques is as imperative
as the integration of body self and psychological self” (p. 325). According to Krueger and
Schofield, this treatment model relies on the collaboration between a psychiatrist and a
dance/movement therapist to synthesize “mind and body in a cohesive manner” (p. 326).
This model has been used both in the context of an inpatient and outpatient setting and it
is customized according to the patient’s needs.
The goals of this model of treatment are to foster body-mind integration, to help
patients develop the capacity to “symbolize and play” (Krueger & Schofield, 1986, p.
327), and to promote transmuting internalization, a term coined by Kohut, describing the
“inherent impetus to go forward in one’s development” (Rowe & MacIssac, 1995, p. 61).
Although the primary modalities utilized in this model are verbal psychotherapy and
DMT, projective drawing and videotaping are also utilized. Treatment begins by working
with an “internal focus of bodily sensations, feelings, and awareness” (Krueger &
Schofield, 1986, p. 327). This is done in order to simulate a normal development between
infant and mother, and is intended to help the patient actively “define the original body
self in a cohesive manner” (Krueger & Schofield, 1986, p. 327). Treatment then
progresses through the developmental stages, utilizing targeted therapy interventions,
such as mirroring, relaxation, and centering.
Anne Krantz (1999), another dance/movement therapist who works with eating
disordered populations, has created a model of treatment that is based on the methods of
Blanche Evans, a DMT pioneer. Krantz’s model assumes the following:
(a) Meaningful affective information is exchanged between the mother’s and
child’s bodies from before birth throughout development; (b) the body is the
vehicle for expressing and storing life experience; (c) the child requires genuine
interaction with caregivers in order to become a separate individual, able to
connect with others; and (d) where emotion is not experienced, particularly
distressing affects may become misinterpreted or disconnected from psycho-
physical reality. Disconnected affect may lead to symptoms, which impact the
body and behavior. The eating disorder is seen as a cumulative effect of disrupted
development of self, body, affect and relatedness. (p. 84)
According to Krantz (1999), Blanche Evans’ methods revolved around the
principle that “by regenerating the body’s potential to move, both emotional and mental
states can be changed” (p. 84). Given the psychosomatic characteristics of eating
disorders, DMT is uniquely suited for the treatment of this population. In Krantz’s
opinion, women with eating disorders often attribute the origin of their suffering to their
bodies. It appears that one’s body becomes the battlefield for repression, dissociation, and
denial of emotions and sensations. Hence, one can see the applicability of DMT, since it
engages the body as an ally in the treatment process rather than as an impediment. Evans
also hypothesized that individual characteristics and one’s environment influence a
person’s life; and indeed, that stress and trauma can become embedded in the body’s
muscle memory as tensions and restrictions. Evans thus believed that it must be through
movement that these elements are worked out and released. This is done through the
exploration of the unconscious and the individual’s use of defense mechanisms,
resistances, and so forth.
Building on Evans’ theories, Krantz (1999) claimed that many clients with eating
disorders have a predisposition towards the use of dissociation, which leads to a split
between the body and the self, often due to early failures in the mother-infant
developmental process of “experiencing affect, body, self and others” (p. 85). DMT is
thus used to reconnect this split, to achieve a harmonious body, and to aid in the
development of self-knowledge and insight, utilizing the body as a “point of reference,
and a vehicle for expression” (p. 85).
Krantz (1999) also believed that it is through movement that one must address
body image distortions so as to aid in the creation of “a dialogue between the subjective
feelings and attitudes, and the body reality” (p. 86). It is both through movement and
through the therapeutic relationship that the body image begins to clarify itself and
become more realistic.
According to Krantz (1999), sexuality also appears to be of great relevance when
dealing with body image, as it is related to issues surrounding “self-image, autonomy,
and self-assertion; give and take; letting-go and control; intensity of body feelings and
sensations; tension and apathy; and the limits of potential action” (p. 86). Specifically,
Krantz believed that “sexual conflicts are intrinsic to eating disorders, whether or not
sexual abuse has occurred” (p. 87). Krantz further claimed that, for some, the eating
disorder replaces sexual experiences. This hypothesis is based on her observations of
patients associating highly sexualized movements with themes such as eating and
vomiting.
In order to adequately treat women with eating disorders, Krantz (1999) has
suggested that the therapist must be curious as to how the woman defines herself in the
world: her sexual history, her family history, her ability to experience pleasure, and so
forth. This allows the therapist to identify areas in which the eating disorder has
“functioned to prevent the client from knowing about these experiences” (Krantz, 1999,
p. 87). Krantz also states the importance of working with the body, from the very start of
treatment in an expressive way, and of working “with what the client brings” (p. 88).
Krantz utilized several specific methods including mobilization, a technique that
“encourages self-created spontaneous movement exploration and reconnection of
movement and feeling, leading to expanded expressiveness” (Evans, as cited in Krantz,
1999, p. 88). This method is used to help mobilize the body to develop “new alternatives
for movement and expression” (Krantz, 1999, p. 89). Physicalization is also a specific
technique created by Evans and utilized by Krantz to transform “an experience into
action with feeling” (Krantz, 1999, p. 89). This method encourages the patient to
communicate an experience through movement instead of only talking about it.
Physicalization is said to aid in the discovery of inner experiences. Improvisation is

another tool often utilized to awaken the unconscious, which can lead to the discovery of
unused potentials and repressed materials.
Another method called Functional Technique is used as a “non-stylized dance
technique, which is rehabilitative and re-educative” (Krantz, 1999, p. 90). This technique
utilizes specifically targeted movement exercises for the individual so that “as the client’s
feelings change, her body must change in order to physically support the new feeling
state, and to counteract unconscious repetition of the problem” (Krantz, 1999, p. 90).
Homework is also useful as a means of facilitating the applicability of treatment
in the patient’s day-to-day life. According to Krantz (1999), homework can serve “to help
the client study patterns of eating and purging, to identify their emotional triggers, and to
create healthier alternatives” (pp. 91-92). Real life situations are also integrated into the
treatment and explored in order to ease the transition from therapy to everyday life.
Methods, such as rehearsal, are employed to help alleviate anticipatory and situational
anxiety. Although these rehearsals are not strictly DMT-specific, they can help the patient
practice alternative methods for coping with anxiety in a safe environment before having
to confront the real situation.
The methods applied vary depending on the therapist’s individual therapeutic
approach and on the needs of the patient. Stark, Arronow, and McGeehan addressed the
topic of the treatment of individuals with bulimia nervosa in their article,
“Dance/Movement Therapy with Bulimic Patients” (1989). Stark et al. state that dance is
a direct expression of the self through the body and is thus a powerful tool for the
treatment of the eating disorder population. Given the repressive, dissociative, and
somatic nature of this disorder, the authors believe that movement experiences can help
patients reconnect with their body and learn to identify areas of tension that are often
associated with repressed emotions and feelings. Stark et al. also stressed the
development of social skills as an essential part of treatment and asserted the need for the
therapist to support the patient in developing new coping mechanisms and strategies.
Stark et al. (1989), identified three main goals for the treatment of patients
suffering from bulimia nervosa: “(1) the body and its action; (2) interpersonal
relationship; and (3) self-awareness” (Stark, as cited in Hornyak & Baker, 1989, p. 123).
The body and its action represent the idea that one must begin to aid the patient in
activating the body through movement. This allows for the release of areas of tension and
repressed feelings. It is postulated that through this activation of the body, cathartic
release, the development of a more realistic body image, bodily integration and
coordination can occur. When it comes to interpersonal relationships, it is postulated that
through the use of rhythm, a sense of relatedness can occur in the group experience. Such
relatedness through rhythm can foster identification with others; it can allow for the
development of self-awareness and can provide a learning opportunity for new movement
options. Finally, the third goal of self-awareness is based on the concept that, through
movement and the experience of the body, one can promote a deeper sense of self-
understanding and self-knowledge.
According to Stark et al. (1989), other specific goals in the treatment of bulimia
are to:
Develop trust; develop body-awareness and a more realistic body image . . . a
clearer sense of self and body boundaries; encourage autonomy and enhance self-
esteem; encourage more appropriate interpersonal relations, thereby overcoming

loneliness, isolation and depression; and facilitate identification, tolerance, and
expression of emotion in appropriate, constructive ways. (p. 127)
Having discussed treatment goals, corresponding examples of movement interventions
are then presented. These are discussed in terms of Mahler’s object-relations theory. The
first goal presented is that of developing trust in the therapeutic relationship, as it mirrors
the original symbiotic relationship between infant and caregiver. However, special
attention is brought to the fact that there is often a need to address nurturance, safety, and
acceptance before a trusting relationship with the patient can be established. Elements
such as body awareness and body trust might also emerge as elements needing to be
negotiated before the development of a trusting relationship can occur. To illustrate these
concepts, several specific interventions are listed accordingly.
The first example highlights empathizing with the patient through mirroring and
synchronization in order to understand the patient more clearly and to give the patient the
“experience of being understood and accepted on an unconscious body level” (Stark et
al., 1989, p. 128). Next, the use of touch and massage is elicited to aid in the development
of trust.
The following sets of interventions are aimed at increasing body awareness and
promoting positive body image. Stark et al. (1989) suggested that through increased body
awareness, one can begin to differentiate their own bodily signals, thus creating a sense
of control over their “body and eventually over the external world” (p. 130). To aid in the
development of this bodily awareness, simple use of breath is of utter importance. It is
through rhythmic and synchronized breathing that a special and intimate relationship is
developed between mother and infant, thus it is an essential tool for the therapist.
Breathing is also used as a tool in the reconnection with the body, which often leads to
the discovery of areas of tension and sensation. Other means utilized in the development
of body awareness are interventions, such as body scans and focalization on specific body
parts. Techniques such as Feldenkrais, Alexander, and the Bartenieff fundamentals can
also be used (Stark et al., 1989, p. 132).
For women with BN, the development of body awareness is essential in laying the
foundations for the formation of positive body image. This, in turn, can help establish a
sense of self, differentiation and body boundaries. Stark et al. (1989) point to the
importance of developing strong body boundaries as this helps patients with BN contain
and tolerate “the intense feelings they have previously controlled through binging and
purging” (p. 133).
The next Malherian phase is that of separation-individuation, which is associated
with the development of autonomy and self-esteem. To begin the developmental process
of establishing autonomy, Stark et al. (1989) emphasized the need for patients to
experience “their real body center and the two weight centers. This includes a clear sense
of balance and awareness of stability and mobility in both the upper and lower parts of
the body” (p. 135). Having renegotiated the separation-individuation process, one must
begin to learn about the other/not-me modes of social interaction and ways of developing
healthy and appropriate interpersonal relationships.
The next treatment step is associated with the rapprochment phase in Mahler’s
developmental theory, which deals with interpersonal relationships. Since social isolation
is often associated with mental illness, it is of great importance to aid the patient in
reconnecting with others and developing appropriate relationships with peers. These
elements are thought to help sustain remission. It is often postulated that people with
bulimia have great difficulty being authentic in relationships and that “the real self in
touch with spontaneous impulses, feelings, and desires is split off and repressed. As a
result, bulimics often attempt to validate themselves through others” (Stark et al., 1989, p.
137). It is therefore important for the dmt to devise interventions that help these patients
reconnect with their bodies and rekindle their creative expression to yield increased
pleasure from genuine social interactions.
The last goal in treatment, as defined by Stark et al. (1989), is “authentic self-
expression” (p. 139). The authors associate this goal with the developmental process of
object constancy, in which the child’s “own individuality begins to consolidate and one’s
contradictions find some resolution” (Mahler et al., as cited in Stark et al., 1989, p. 139).
It is through authentic self-expression that previously intolerable feelings can emerge and
that the patient can begin to reclaim control of his or her body and of him or herself in
relation to others. The development of authentic movements can also help the patient
learn modes of self-regulation.
In order to help women suffering from bulimia nervosa reclaim and find their
authentic self, a method known as authentic movement is often used as a modality of
treatment for this population. Authentic movement was created by Mary Stark
Whitehouse and was highly influenced by Jungian theory, in particular by a concept
known as active imagination:
The process Jung used was meant to provoke unconscious images using as little
conscious intervention as possible. The patients were instructed in how to become
conscious witnesses of their own unconscious process and then to enter the scene,
becoming part of the picture or action. After the images stopped, the patients were
asked to write, draw, or paint the story. (Taylor, 2007, p. 48)
Whitehouse worked with this idea and applied it somatically, utilizing movement as the
means of tapping into the unconscious process. Indeed, this method focuses on the
internal experience of the person moving and, consequently, the therapist’s role is
indirect, as the observer/witness. It is a powerful tool, as Musicant (2001) described:
The mover is involved in an immediate, direct, and intimate relationship with the
self in the presence of another. This process can be profound as clients are seen
and accepted as they enter the unknown in themselves and listen deeply to
themselves. For those whose relationship to their own knowing has become
distorted, this process can be both challenging and healing. (p. 20)
As seen above, there are many approaches for the treatment of women with
bulimia nervosa, even within the field of DMT. It is thus one goal of this study to directly
solicit information from experienced DMT practitioners to evaluate the existing methods
and to put forth a comprehensive overview of movement interventions.

Methodology
Rationale
According to Wilson, Grilo, and Vitousek (2007), “The development of more
efficient treatments will depend on improved understanding of the mechanisms whereby
psychological treatment produces therapeutic change” (p. 205).
Building on this concept, a case study design (Cruz & Berrol, 2004, p. 72) was
used for this study, which focused on the analysis of the current use of DMT as a primary
means of treatment for women suffering from bulimia nervosa. In particular, the
principal investigator sought to understand when and how DMT could be utilized and
what factors conditioned the effectiveness of this therapy.
For this purpose, the investigator reviewed relevant literature and solicited input
from professional dance movement therapists with significant experience and recognized
expertise in treating bulimia in North America.
The goal of the study was to compile the learning acquired from therapists with
the knowledge selected from the literature review into a treatment manual for
practitioners working with women suffering from bulimia nervosa and utilizing
dance/movement therapy as the primary modality for treatment.
The manual, which will be presented as a pocket appendix, would cover the
following main topics:
1. ED fundamentals
2. Etiology
3. Eating disorder symptoms
4. Diagnosis
5. DMT treatment themes
6. DMT treatment goals
To begin with, the principal investigator conducted a review of the literature,
utilizing primarily scholarly, peer-reviewed, and primary source references when
possible. Secondary and tertiary references were only used when primary sources were
unavailable. In order to adequately understand the population being studied and to
increase the reliability of the information and the hypotheses or conclusions drawn, the
principal investigator incorporated literature from a variety of fields including
psychology, psychiatry, nursing, social work, and alternative therapies. Through this
research, an update of the etiology, development, and maintenance of bulimia nervosa in
women, as well as treatment implications, was obtained.
Apparatus
Input from experienced DMT therapists was acquired through a questionnaire (see
Appendix A) created by the author and distributed for completion to registered
dance/movement therapists. The questionnaire was designed according to the knowledge
and guidelines extracted from the literature review. The questionnaire design aimed at
gaining firsthand knowledge from the experienced clinicians concerning the mechanisms,
characteristics, and treatment implications for patients with BN. It was also utilized to
evaluate proposed movement characteristics observed in women diagnosed with bulimia
nervosa, as well as to assess the relevance and effectiveness of specific movement
interventions selected from DMT literature. Another goal of the questionnaire was to
examine the roles of transference and countertransference between patient and therapist.
The last goal was to understand modes of self-preservation used by the therapists.
The 15 questions developed to address all these elements were composed as
follows: The first three questions requiring short answer responses were utilized to obtain
information on the therapists, their experience, and their professional orientation;
Questions 4-7 consisted of Likert scale responses evaluating characteristics of the
selected population and prompting for further information; Questions 8-10 evaluated
specific interventions; and Questions 11 and 12 utilized both Likert scale responses and
short answers to explore the therapists’ use of transference and counter-transference. The
remaining questions sought to explore the effect, if any, of this work on the therapist and
her/his methods of self-preservation.
As stated, the questionnaire was ultimately developed and utilized in order to
assess the accuracy of information gathered through the review of literature and to
evaluate specific interventions for their potential inclusion in the final manual.
Participants
Participants were recruited on a voluntary basis through extensive e-mailing (see
Appendix B), to the American Dance Therapy Association’s (ADTA) listserv and
through personal contacts of the investigator. The participants ultimately recruited were
female. Two dance movement therapists were located in New York, one in Florida, and
one in Canada. The participants worked both in individual and group treatment settings,
such as inpatient hospitalization programs, outpatient day treatment, and private practice.
To qualify for participation in this study, participants were required to be registered dance
therapists (ADTR) by the American Dance Therapy Association and have a minimum of
5 years experience treating patients with eating disorders.
Procedure
Participants were asked to complete the questionnaire that was submitted either
electronically, via a secure email account, or via a hard copy, and an optional semi-
structured interview was utilized when deemed necessary.
In order to abide by ethical standards established by Pratt Institute, by the ADTA,
and by the American Psychological Association (APA), each participant was required to
fill in a consent form (see Appendix C) informing them of the potential risks and benefits
of participating in the study. Participation in this study was voluntary, and all participants
were informed of the purpose of the study and of their right to refuse and/or to cease
participation at any time without consequences. Participants were treated with the utmost
respect and in accordance with standards established by the organizations mentioned
above.
Participants were encouraged to respond within 45 days upon receipt of
questionnaire and to complete and return documents to the principal investigator. No
remuneration was attributed to participants. All sensitive information was kept in a
locked drawer by the investigator in her locked apartment. To further ensure privacy,
each participant was assigned a confidential code. The response data was then coded by
an alphabetical system identifying the participants.
Following receipt of the completed questionnaires, the principal investigator
evaluated the need to utilize a 30-minute semi-structured interview (see Appendix D) to
further clarify or to expand on information gathered from the questionnaires. These semi-
structured interviews were to be conducted via phone or in person, depending on the
availability of the participants. The responses to the questions were to be recorded via
note taking and/or via voice recording.
To ensure the security of sensitive material, all data will be deleted and destroyed
within 6 months of completion of the thesis project and the email account will be
permanently closed. Hard copies of information will be retained for no less than 3 years.
No other person will have access to the information.
Data Collection and Analysis
The quantitative data gathered from the questionnaire was summarized in four
sections of the Results chapter: treatment goals and themes that emerged during
treatment, movement characteristics specific to patients with BN, specific movement
interventions, transference, countertransference, and self-care of the therapist. For each
numerical question (scored on a Likert scale, ranging from 1 to 5) response frequency
was calculated to assess its relevance for inclusion in the manual. All data was
summarized in a table (see Appendix E). Qualitative responses were transcribed and
summarized for each participant according to section themes. When necessary, direct
quotations were used to remain authentic to the answers provided by the participants.
These responses were included in the manual according to topic and relevance for
treatment. Only data deemed relevant was compiled to create a DMT manual for
practitioners treating women with bulimia nervosa.

Results
The following section consists of a descriptive analysis of the data collected via
responses to the questionnaire (see Appendix A). A mass email (see Appendix B) was
sent to the American Dance Therapy Association listserv and four respondents expressed
interest in participation and represents the final sample size.
The identities of the dance therapists were kept confidential through letter coding
(A, B, C, and D). Each dance/movement therapist had a minimum of 10 years clinical
experience with an eating disordered population. Participants A, B, and C had over 45
years of cumulated experience working with women with eating disorders. Participant D
was not included in this calculation as this particular question was left blank.
The questionnaire consisted of Likert scales ranging from 1 to 5 and short answer
questions which sought to explore the mechanisms, characteristics, treatment
implications, and movement characteristics of this population. It also sought to assess the
applicability, utility, and effectiveness of specific movement interventions, to examine
the roles of transference and countertransference between patient and therapist, and to
understand modes of self-preservation used by the treating therapists. Data was scored
accordingly. For a full description of the raw data and select writing samples please see
Appendix E.
After an in-depth review of the data (as presented in Appendix E), only significant
findings will be presented in the following sections: DMT theoretical practices, treatment
goals and themes, movement characteristics, movement interventions, transference and
countertransference, and therapist’s self care.
Significance of the data from the entire questionnaire was determined by the
principal investigator based on repetition of themes found in the literature and in the
participants’ responses. Also, based on the thorough responses and wealth of information
gathered via the questionnaires, the optional interviews were not utilized as initially
outlined in the Method Section.
DMT Theoretical Practices
As highlighted previously in the literature review, it appears that DMT is uniquely
suited for the treatment of eating disorders and, in particular, of bulimia nervosa. As
specified in the Psychodynamic Diagnostic Manual, people suffering from bulimia often
experience feelings of numbness, as well as feelings of disconnection from or confusion
about the body (PDM Task Force, 2006, p. 120). According to participant B “all
successful therapy involves an interaction between the mind and the body.” This concept
of body-mind integration is a primary focus in DMT. Indeed, DMT is the
“psychotherapeutic use of movement as a process which furthers the emotional, physical
and cognitive integration of the individual” (ADTA, as cited in Levy, 2005, p. 11).
Keeping the body-mind connection as an omnipresent guideline, the DMT
participants reported utilizing dance/movement therapy theories as a basis for their
practice. The dance/movement therapists reported utilizing concepts advanced by field
pioneers, including Marian Chace, Mary Whitehouse, and Blanche Evans. They also
reported being influenced by prominent psychological figures, such as Sullivan and Jung,
and adhering to concepts put forward by psychoanalytic, feminist, object-relations, and

attachment theoreticians. As presented in the literature review, through the exploration of
various DMT treatment theories, such as Krantz (1999) and Stark et al. (1989), it is
visible that there are many ways within DMT to approach the treatment of BN. This
element of variety was salient as participants reported informing their approaches to
therapy through different means.
Treatment Themes and Goals
Having explored the dance/movement therapists’ theoretical frameworks and
clinical experience, the questionnaire sought to further explore their methods of
treatment. In particular, it sought to understand and predict therapeutic goals and themes
that might emerge over the course of treatment. Several goals appeared to emerge
consistently throughout the literature, among which reducing binge-purging behavior,
addressing body image distortion, increasing one’s ability to self-regulate, increasing
one’s connection to one’s body, and expanding one’s movement vocabulary, spatial
awareness, and spontaneity. These goals were evaluated in the questionnaire through a
Likert scale, ranging from 1 not applicable to 5 extremely relevant (see Appendix E,
Question 4). Participants A, B, C, and D all rated reducing binge/purge behaviors,
increasing self-esteem, and increasing a sense of body-self as extremely relevant. Both
participant A and B rated all of the above goals as extremely relevant and participant C
and D rated the above goals from relevant to extremely relevant, thus supporting their
importance and relevance for treatment. The participants were also invited to share goals
specific to their practices. Responses included: improving social skills, helping manage
stress, increasing one’s ability to express emotion, increasing creativity and play, and
understanding one’s relationship to food and eating (see Appendix E).

Predominant themes emerging throughout the course of treatment were also
evaluated in the questionnaire through a Likert scale, ranging from 1 never to 5 all the
time (see Appendix E, Question 5). These themes were evaluated in order to increase the
principal investigator’s general therapeutic knowledge and to aid in the development of
specific and efficient movement interventions to be included in the final manual. The
theme of control was rated as emerging often by participant C to all the time by A and B.
The DSM-IV-TR (2000) text revision indicates that elements of losing control emerge for
those suffering from bulimia, especially surrounding instances of bingeing and purging.
The theme of control was again referenced by Krantz (1999) and was hence deemed
significant. The DSM-IV-TR (2000) text revision also alludes to depression, which
participants also rated as emerging often to all the time. Anxiety also stood out, both in
the literature and in the responses to the questionnaire, and was therefore deemed
significant. The theme of most important significance was that of shame. As all 4
participants rated it as emerging all the time.
Once again the participants were given the opportunity to share themes that they
considered relevant. Participant D suggested the inability to experience pleasure.
Participants B and C mentioned various forms of trauma (developmental, violence, and
neglect). As Truer et al. (2005) have stated, there appears to be a positive correlation
between abuse and the development of bulimia nervosa. In fact, Leonard et al. (as cited in
Brewerton, 2007) conducted a study in which “women with bulimia nervosa reported
higher levels of CSA, childhood physical abuse, and combined childhood sexual/physical
abuse compared to the non-eating-disordered women” (p. 289). Thus, trauma as a general
category was deemed of high significance.

Movement Characteristics
According to Stark et al. (1989) and Deihl (1999), there appears to be movement
characteristics that are specific to women with bulimia nervosa, which include stopping
and going, lack of shaping, rigid pelvis, and so forth (p. 45). The questionnaire evaluated
the suggested movement characteristics found most often in the literature and their
relevance in current DMT practices through a Likert scale, ranging from 1 strongly
disagree to 5 strongly agree (see Appendix E, Question 6). For this question, participant
A’s answers were not incorporated as she reported, “guessing” to respond that she does
not “access in this way.” Out of the 7 movement characteristics proposed in the
questionnaire, 4 were deemed significant. These four characteristics were described as
relevant in the literature and the participants agreed and strongly agreed that these
movement patterns were characteristic of women with BN and the characteristics were
mentioned either directly or indirectly in the optional responses (Question 7). The
characteristics deemed significant were: a lack of movement in the chest, rigidity of the
pelvis area, a primary utilization of peripheral movements, and an indirect use of space.
Participants B and C also provided supplemental input and suggested several other
characteristics including: “lack of integration between upper and lower body”; “lack or
energy in or connection to the pelvis”; “agitated urgency and little sense of time”; and
“minimal movements in the near reach zone.” For movement characteristics there
appeared to be less agreement between participants in comparison to previous questions.

Movement Interventions
Having examined individual approaches to therapy, goals, themes, and movement
characteristics, the next step was to explore the actual therapy process as seen through the
utilization of specific movement interventions. These interventions were taken from
examples offered in the DMT literature (Deihl, 1999; Krantz, 1999; Krueger & Schofield,
1986; Stark et al., 1989; Totenbier, 1995).
Overall, the responses to this question were quite different for each participant.
Responses ranged from 1 never use to 5 use all the time (See Appendix E, Question 8).
There were three categories of movement interventions were rated as use often (4) to use
all the time (5) by 3 of the dance/movement therapists and hence deemed significant.
These were improvisation, centering exercises and relaxation techniques. Participant C
reported utilizing authentic movement all the time. Apart from the significant use of
improvisation, centering, and relaxation techniques, no other conclusions were drawn
from this question. It appears that the dance/movement therapists’ background and
informing theories influence their choice of interventions.
Continuing with the evaluation of specific movement interventions, 11
interventions were described (see Appendix E, Question 10) and the dance/movement
therapists were asked to evaluate them via a Likert scale, ranging from 1 not effective to 5
extremely effective. Here, again, it was difficult to find sufficient participant agreement,
as the responses were quite diverse. Nevertheless, the use of physicalization was
evaluated by 3 participants (A, B, and C) as extremely effective and hence deemed
significant by the principal investigator. Participants suggested other interventions

including: mirroring, walking meditation, focus based exercises, and sculpting of feeling
states. Participant A reported that she “work[ed] with process rather than providing
specific dance techniques.” She reported picking up on and developing the patients’
movements, emotions, and verbalizations in order to understand and help them
understand their issues.
Transference and Countertransference
Having explored the treatment process and the characteristics of this population, it
was of interest to explore the experience of the treating therapists through their use of
transference and countertransference. This was done via a Likert scale, ranging from 1
never use to 5 use all the time (see Appendix E, Question 11). Participants A, B, and C
reported using transference regularly to all the time. Participant D reported not using it at
all as she worked in a short-term setting. However, its use was deemed significant. Freud
(as cited in Dosamantes-Beaudry, 2007) originally referred to transference as the
“patient’s reproduction of past relationships in the current relationship established with a
neutral analyst” (p. 75). This definition has evolved over the years, but is generally
understood as “an unconscious phenomenon in which the patient transfers core feelings,
ideas, and methods of relating onto the figure of the psychoanalyst” (Waska, 2008, p.
333). Dosamantes-Beaudry also referred to somatic transference, which she defined as
the following:
The totality of the patient’s bodily-felt experience and enacted behavior
(experienced as bodily-felt sensations and expressed via bodily-felt expressive
movement and through kinesthetic and kinetic images) that function as

transitional objects for the patient and provide critical relational psychodynamic
meaning that at the outset of treatment is unknown to the patient. (p. 76)
Participant A reported utilizing transference “sometimes actively and sometimes
passively,” either verbally or through movement, situation depending. Participant B
described transference as “important diagnostic information” that allows her to gain
important information about clients and their inner world. She also utilizes transference
to guide her in her work with individuals. Participant C explained that she too used
transference as a way of gathering information about the client, but that she only
addressed it with the client when deemed necessary and/or beneficial for the client and
the therapeutic process.
Next, participants’ use of countertransference was rated via Likert scale, ranging
from 1 never to 5 use all of the time (see Appendix E, Question 12). Participant A
reported using countertransference regularly, participant B rarely, participant C
moderately, and participant D all the time.
According to Racker (as cited in Dosamantes-Beaudry, 2007), there are two forms
of countertransference:
(a) concordant countertransference reactions in which the analyst felt compelled
to identify empathically with the patient’s thoughts and feelings and (b)
complementary countertransference reactions where the analyst experienced
himself being transformed by the patient into an unwanted or despised aspect of
the patient’s self. (p. 75)
Participant A alluded to countertransference as a means of gathering information
about patients. Similarly, participant D reported that the use of countertransference

served as a means “to understand metaphors of their [the patient’s] experience and to
understand useful and not useful responses within the context of the therapeutic
relationship. Participant A emphasized, however, that it “always need[s] to be considered
as hypotheses, not the ‘truth’ of the client.” Participant A reported paying attention to the
emotions/feelings that emerge for her in the therapeutic relationship and seeking to
understand the underlying issues that are emerge for the patient. She gave the example of
feeling anxious, angry, or impatient as a potential indicator of the patient’s fear of
survival or of annihilation. She reported holding these emotions and reflecting them back
to the patient in a more neutral manner that allows the patient to work with them in a less
threatening fashion. Participant A also referred to the use of somatic countertransference,
which is of particular interest to the field of DMT. She defined somatic
countertransference as cues that emerge in her own body that may be “clues to what
might be happening in clients.”
Dosamantes-Beaudry (2007) defined somatic countertransference as “somatic
reactions a therapist has toward her patient at a particular moment during treatment” (p.
76). Orbach (2004), a leading psychologist in the field of eating disorders, also argued
that, contrary to popular trends, one must pay attention to these body symptoms that
patients bring forth, as they can serve as fundamental keys to the patient’s mental state
and may potentially be signs of “disorganized body attachment(s)” (p. 142).
In a similar fashion, participant C reported beginning a session by noticing what is
occurring in her body and by assuming that the countertransference is induced. She then
questions what patients want her to know about them. However, she reported not
involving her countertransference directly into the session, but rather using it to
understand the client’s experience.
Participant B chose not to respond to this question and gave no explanation.
Therapist’s Self-Care
Considering the fact that the dance movement therapist utilizes her body in a
multitude of ways in the therapeutic relationship, it seems inevitable that this work would
have an effect on her. The questionnaire sought to understand if indeed this was the case
and if the participants’ work with women suffering from BN affected their sense of body-
self and their body image (see Appendix E, Question 13). Participants were asked to
evaluate the effect of their work via a Likert Scale, ranging from 1 never to 5 most of the
time. Participant A reported the work rarely affecting her. Participant D reported it
affecting her sometimes in that her use of eating as a defense mechanism was heightened.
Participant B reported it affecting her more than often in that it has made her highly
aware of ways in which she has “been brainwashed by the cultural images of beauty and
[she has had] to work to counteract those consciously to find all bodies beautiful.” In her
own words, “It has affirmed and strengthened the commitment of my own journey to
value my body as home and expression of my presence in the world.” Similarly,
Participant C also reported a heightened awareness of cultural ideals of beauty, but that
this work had predominately brought more awareness to her own relationship with food
and eating.
Methods of self-care were then explored (see Appendix E, Question 15). The
main methods utilized overwhelmingly by all 4 therapists were one-on-one supervision,
peer supervision, and group supervision. The other self-care options were rated according
to personal preferences. Due to unclear participant completion of this question, specific
ranking could not be determined.
In conclusion, it is apparent that the dance/movement therapists selected to
participate had extensive clinical experience working with women with eating disorders
and, in particular, with women suffering from BN. Although all trained in DMT, the
therapists differentiated themselves by their individual approaches to therapy. Through
their responses, significant elements concerning the BN population were deduced. First,
therapeutic goals that emerged as significant were those of reducing binge/purge
behaviors, increasing self-esteem, and deepening a sense of body-self. The unanimous
theme that emerged as significant was that of shame. Movement patterns were difficult to
assess, due to little agreement in the responses. As far as proposed interventions,
improvisation and physicalization emerged as significant. Transference was deemed
important as a diagnostic tool and was often utilized, whereas countertransference was
utilized much less frequently. The therapist’s self-care evaluation was difficult to score as
responses varied, but the three following modalities emerged as significant: one-on-one
supervision, peer supervision, and group supervision.
Overall, there was significant agreement on elements surrounding psychological
factors and characteristics of this population. However, the picture became unclear
around questions concerning DMT theories and practices. What does this mean and what
are the implications for the use of DMT as a therapeutic modality for this population?
These questions need to be examined through more extensive surveys as suggested in the
discussion chapter.
Discussion
In an effort to understand the increasing prevalence of BN in today’s society
(despite the available treatments), the principal investigator evaluated current literature
and research. In addition, experienced dance/movement therapists were surveyed about
characteristics and needs of patients with BN, themes emerging during treatment,
therapeutic goals, treatment methods, specific movement interventions, and self-care of
the therapist. The ultimate goal of this research was to compile a pilot manual for
therapists utilizing DMT as the primary modality in the treatment of women with BN (see
Pocket).
Findings
Literature review. The literature review provided a summary of the fundamentals
that dance movement therapists need to know when applying their skills to the treatment
of eating disorders, and specifically to BN. However, this review identified more
information about causes, symptoms, and therapeutic goals associated with BN illness
but less input about themes for intervention and recommendations for specific movement
patterns. The literature review also helped reveal the most significant factors and methods
of treatment available, to date, for the construction of the proposed manual.
Questionnaire. The questionnaire utilized for this case study contributed a rich
and diversified qualitative input. Through it, the author was able to gain insight into the
practices of four experienced dance/movement therapists. The information gathered via

the questionnaire confirmed elements found in the literature and revealed areas needing
clarification and further exploration.
The data collected via the questionnaire served to support and confirm the themes
and goals of treatment considered relevant in the literature, but also allowed the
participants to share information and thoughts on other goals and themes that they
deemed important. The questionnaire also served to evaluate the current usage and
applicability of specific methods and interventions and allowed the author to collect
further information and ideas for specific movement interventions to be compiled in the
pilot manual. The questionnaire also helped bring to light areas that needed further
exploration; namely, better insight into the actual use (how, when, and why) of specific
interventions, a need to further monitoring and recording patient’s responses to the
different interventions, a systematic and normalized recording of the patient’s progress,
and so forth. Furthermore, it served to highlight the diversity and wealth of options one
has to choose from when utilizing DMT methodology.
In light of these findings, the principal investigator suggests that for future
research which utilizes this thesis model, the questionnaire be further revised to help
clarify elements such as dance/movement therapists’ training, reasoning for the
utilization of specific methods, and means through which effectiveness of methods were
established, in addition to the areas mentioned above. The author believes that this would
help researchers better understand the usage of DMT with women suffering from BN,
allow for an more thorough review of current treatment options, and allow for a more
complete conceptualization of a treatment manual.

Significant Findings and Recommendations
Need for collaboration. The information gathered through the literature review
and the results collected via the questionnaire support the premise that DMT is an
appropriate means of treatment for BN, due to the somatic nature of BN and the body
oriented approach of DMT. It is also apparent, through the debate surrounding the
etiology of BN (medical and psychological), that there are multiple dimensions that must
be taken into consideration for the effective treatment of this illness. It is hence apparent
that preserving current team model of treatment is essential, but that the inclusion of
DMT in this model could contribute infinitely towards a more holistic and effective
treatment plan.
Need for Further Clarification and Exploration
Validity and reliability. As seen in the literature review, there are various methods
recorded by experienced DMT clinicians that have been deemed efficient (Deihl, 1999;
Krantz, 1999; Krueger & Schofield, 1986; Stark et al., 1989; Totenbier, 1995). However,
it is unclear how the validity, reliability, and effectiveness of these interventions were
established. This lack of information about the methods used to assess specific treatments
was also visible in the questionnaire. It is hence recommended that, upon revision of the
questionnaire, these elements be included and further explored in order to promote
technical validity of DMT methodology.
Conception of movement patterns. Through the literature analysis and the
responses recorded from the questionnaire, it became evident that the translation of
therapeutic goals into specific movement patterns emerged as a major challenge. While
the literature analysis and the surveyed therapists revealed a number of pertinent
movement patterns, this contribution was relatively modest and not sufficiently
documented. Moreover the therapists’ feedback did not exhibit sufficient agreement on
particular movement patterns, but it did show the diversity of movement interpretations.
The literature review showed that specific suggestions for movement patterns originated
from a rather limited number of specialists (Deihl, 1999; Stark et al., 1989). These
observations show that DMT applied to BN has established some solid roots, but it is a
rather young discipline, which is still in the freelance experimentation phase. The author
believes that this is perhaps a normal evolution and that it could explain the current
diversity of approaches and prevailing disagreements.
Utilization of specific interventions. Significant concepts that emerged from the
questionnaire were an emphasis on the therapist-patient relationship and the therapist’s
ability to utilize elements such as transference and countertransference. These elements
emerged as techniques utilized to further understand the patient’s experience as an
individual and, in response, to tailor the treatment towards their specific needs.
Thus, it seems essential that DMT be practiced with great flexibility and openness
and that the therapist remains dynamic in order to cater to the individual’s healing
process. It is within this framework that the specific movement interventions were
evaluated.
Visible in the literature was the utilization of specific DMT methods, such as
physicalization and improvisation. These and other DMT interventions were evaluated in
the questionnaire in order to assess their utility and applicability in the treatment of
women with BN. This evaluation clarified the therapists’ preferences and agreement on
the most effective interventions and underlined the flexibility with which one can practice
DMT. It also served to focus the selection of interventions to be included in the final pilot
manual.
There was, however, a visible lack in the literature on the specific application and
utilization of these interventions. There were no specific guidelines and one was left to
speculate as to their applications for individual or group settings, age appropriateness,
and so forth. These elements bring attention to the notable lack of outlined guidelines for
dance/movement therapists. Indeed there are no diagnostic or evaluative tools, such as the
DSM-TR-IV (2000) text revision, that help classify and organize acquired information. It
is evident that further investigation of standardized methods for diagnosing and treating
would be of great benefit to the field and for the teaching and transmission of knowledge
to colleagues in other medical domains, as well as, to new dance/movement therapists.
This may be a shortcoming of the questionnaire in that it did not sufficiently explore the
ways in which these methods were used. In consequence, the author would encourage
further clarification and exploration of the ways in which these interventions are used.
This would ultimately aid less experienced DMT clinicians in properly using the
proposed methods.
Monitoring DMT effectiveness. In acknowledging that DMT application to BN is
a relatively young discipline where creative experimentation by dance/movement
therapists prevails, there are several aspects that merit further attention. The author
believes that it is critical to formalize the process of monitoring the patient reactions, the
effectiveness of the movement interventions, and the coherence of all professional
interventions. This would not only help clarify the therapeutic process for less
experienced dance/movement therapists, but it would also help to validate the field of
DMT at large. However, it appears that this important monitoring aspect has not yet
received sufficient attention, structuring, and coordination. Although this is not the sole
responsibility of DMT practitioners, the author encourages dance/movement therapists to
take a proactive role, possibly with the help of the ADTA, in shaping the monitoring
process and standards of treatment.
Therapist self-care. The literature review and feedback from the surveyed
therapists confirmed adequate awareness of the importance of self-care. It brought
attention to the critical use of supervision. The author believes that the use of supervision
demonstrates a willingness to examine one’s shortcomings and a desire to constantly
improve one’s ability to treat clients.
However, the extent and ways in which supervision is utilized was not clear. This
may be of interest for future examination to better understand therapists’ individual
therapeutic approaches and processes. It could further clarify the reasoning and
methodology behind specific interventions, which would be of great interest for the
future development of standardized methods and the development of treatment manuals.
Considering the level of direct mental and body involvement devoted by
dance/movement therapists to BN therapies, this author recommends that the DMT
community secures self-preservation through the identification of more self-care
techniques and training for their application. A meaningful initiative in this direction
would be to further organize with the ADTA and other BN health professional events,
such as national/international surveys, symposiums, and dedicated project task forces to
promote exchange and build consensus on best practices.

Study Limitations
As in all research, unexpected limitations to this study emerged and reduced the
investigator’s ability to collect appropriate and relevant data. The first limitation and
perhaps the most significant one, was the limited timeframe and lack of funding. This in
itself restricted the sample size and the overall ability of the principal investigator to
conduct a more in-depth exploratory study. In particular, the author believes that future
studies would greatly benefit from the utilization of longitudinal outcome studies.
The limited number of willing participants was also a large impediment in this
study. Although, an email was sent to over 50 dance/movement therapists, only two
responded. The other two dance/movement therapists were recruited via personal request
of the principal investigator. It is unclear why so few dance/ movement therapists
responded. One might hypothesize that some dance/movement therapists might have
been reluctant to share therapeutic knowledge because of the difficulties translating their
work into words. Others might underline the possibility of resistance (perhaps
unconscious) to the development of the DMT field. Other practical considerations, such
as a lack of time, a lack of interest in the study, no compensation for completion, and so
forth could also have contributed to the low response rate.
In conclusion, this investigation has confirmed that the application of DMT to BN
is pertinent, but it is still in its developmental stage, which requires acceleration and
dealing with important issues such as those highlighted in the discussion. Future growth
and credibility of DMT application to bulimia would benefit from further consolidation
of DMT research advance, as well as from stronger coordination of interventions by all

disciplines concerned with bulimia. This would further promote a holistic approach to the
treatment of BN in balance with its multifactorial complexity.

References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders (4th ed.) text revision. Washington, DC: Author.
Beattie, H. J. (1988, July). Eating disorders and the mother-daughter relationship
[Electronic version]. International Journal of Eating Disorders, 7(4), 453-460.
Benninghoven, D., Jürgens, E., Mohr, A., Heberlein, I., Kunzendorf, S., & Jantschek, G.
(2006, March/April). Different changes of body-images in patients with anorexia
or bulimia nervosa during inpatient psychosomatic treatment [Electronic version].
European Eating Disorders Review, 14(2), 88-96.
Brewerton, T. D. (2007). Eating disorders, trauma, and comorbidity: Focus on PTSD.
Eating Disorders, 15, 285–304. doi:10.1080/10640260701454311
Cash, T., & Deagle, E., 3rd. (1997, September). The nature and extent of body-image
disturbances in anorexia nervosa and bulimia nervosa: A meta-analysis. The
International Journal Of Eating Disorders, 22(2), 107-25. [Electronic version].
Dosamantes-Beaudry, I. (2007, Winter). Somatic transference and countertransference in
psychoanalytic intersubjective dance/movement therapy. American Journal of
Dance Therapy, 29(2), 73-89. doi:10.1007/s10465-007-9035-6
Eggers, C., & Liebers, V. (2007). Through a glass, darkly. Scientific American Mind,
18(2), 30-35. Retrieved March 20, 2009, from New York Public Library –
EBSCOhost Web site: http://nylp.org
Gillespie, J. (1996). Rejection of the body in women with eating disorders. The Arts in
Psychotherapy, 23(2), 153-161.

Grabe, S., Hyde, J. S., & Ward, L. M. (2008). The role of the media in body image
concerns among women: A meta-analysis of experimental and correlational
studies. Psychological Bulletin, 134(3), 460-476. doi:10.1037/0033-
2909.134.3.460
Hornyak, L. M., & Baker, E. K. (Eds.). (1989). Experiential therapies for eating
disorders. New York: The Guilford Press.
Kaye, W. (2008). Neurobiology or anorexia and bulimia nervosa. Physiology &
Behavior, (94), 121-135. Retrieved March 20, 2009, from
http://www.sciencedirect.com
Kleinman, S. (2008, October). Challenging body distortions through the eyes of the body.
Retrieved January 9, 2008, from http://www.eatingdisorderhope.com/body-
distortions.html
Kleinman, S., & Hall, T. (2005). Women with eating disorders. In F. Levy (Ed.), Dance
movement therapy: A healing art (2nd rev. ed., pp. 221-228). Reston,VA:
National Dance Association. (Original work published 1988)
Krantz, A. M. (1999, Fall/Winter). Growing into her body: Dance/Movement therapy for
women with eating disorders. American Journal of Dance Therapy, 21(2), 81-
103.
Kruger, D., & Schofield, E. (1986). Dance/movement therapy of eating disordered
patients: A model. American Journal of Dance Therapy, 13, 323-331.
Lausberg, H. (1998, Fall/Winter). Does movement behavior have differential diagnostic
potential? Discussion of a controlled study on patients with anorexia nervosa and
bulimia. American Journal of Dance Therapy, 20(2), 85-99.

Maine, M., Davis, W. N., & Shure, J. (Eds.). (2009). Effective clinical practice in the
treatment of eating disorders: The heart of the matter. New York: Routledge,
Taylor & Francis Group.
Mitchell, S. A., & Black, M. J. (1995). Freud and beyond: A history of modern
psychoanalytic thought. New York: Basic Books.
Musicant, S. (2001, Spring/Summer). Authentic movement: Clinical considerations.
American Journal of Dance Therapy, 23(1), 17-28.
doi:10.1023/A:1010728322515
National Eating Disorder Association. (2006). Statistics: Eating disorders and their
precursors [Fact sheet]. Retrieved January 25, 2009, from National Eating
Disorder Association Web site:
http://www.nationaleatingdisorders.org/p.asp?WebPage_ID=286&Profile_ID=41
138
Neuropeptide. (n.d.). In Wikipedia, the free encyclopedia. Retrieved June 3, 2009, from
http://en.wikipedia.org/wiki/Neuropeptide
Orbach, S. (2004, June). What can we learn from the therapist's body? Attachment and
Human Development, 6(2), 141-150. doi:10.1080/14616730410001695349
Russel, T. L., & Ainsworth, M. D. S. (1981, December). Maternal affectionate behavior
and infant: Mother attachment patterns. Child development, 52(4), 1341-1343.
doi:10.1111/1467-8624.ep8861096
Schmidt, U. (2003). Aetiology of eating disorders in the 21st century: New answers to
old questions. [Electronic version]. European Child & Adolescent Psychiatry,
Suppl 1(12), 30-37.

Schneider, J. A. (1995, Spring). Eating disorders, addictions, and unconscious fantasy.
Bulletin of the Menninger Clinic, 59(2), 177-90. Retrieved March 20, 2009, from
Academic Search Premier database.
Siegel, D. J. (1999). The developing mind: How relationships and the brain interact to
shape who we are. New York: The Guilford Press.
Stark, A., Aronow, S., & McGeehan, T. (1989). Dance/movement therapy with bulimic
patients . In L. M. Hornyak & E. K. Baker (Eds.), Experiential therapies for
eating disorders (pp. 121-143). New York: The Guildford Press.
Stern, D. N. (1977). Missteps in the dance. The first relationship; Infant and mother
(pp. 133-156). Cambridge, MA: Harvard University Press.
Taylor, J. (2007, March). Authentic movement: The body’s path to unconsciousness.
Body, Movement and Dance in Psychotherapy, 2(1), 47-56.
doi:10.1080/17432970601025402
Totenbier, S. L. (1995). A new way of working with body image in therapy,
incorporating dance/ movement therapy methodology. In D. Dokter (Ed.), Art
therapies and clients with eating disorders (pp. 193-207). Philadelphia: Jessica
Kingsley Publishers.
Truer, T., Koperdak, M., Rozsa, S., & Furedi, J. (2005). The impact of physical and
sexual abuse on body image in eating disorders. European Eating Disorders
Review, 13, 106-111. Retrieved March 20, 2009, from ebscohost database:
http://nypl.org
Vanderlinden, J. (2008, September/October). Many roads lead to Rome: Why does
cognitive behavioral therapy remain unsuccessful for many eating disordered
patients? European Eating Disorders Review, 16(5), 329-333.
doi:10.1002/erv.889
Waller, G., & Sheffield, A. (2008, April). Causes of bulimic disorders. Psychiatry, 7(4),
152-155.
Walsh, T. B., & Devlin, M. J. (1998, May 29). Eating disorders: Progress and problems.
Science, 280(5368), 1387-1390. doi:10.1126/science.280.5368.1387
Waska, R. (2008). Using countertransference: Analytic contact, projective identification,
and transference phantasy states. American Journal of Psychotherapy, 62(4), 333-
351. Retrieved March 20, 2009, from
http://search.ebscohost.com/login.aspx?direct=true&AuthType=cookie,ip,url,cpid
&custid=nypl&db=f5h&AN=36011829&site=ehost-live
Wonderlich, S. A., Brewerton, T. D., Jocic, Z., Dansky, B. S., & Abbott, D. W. (1997).
Relationship of childhood sexual abuse and eating disorders. Journal of the
American Academy of Child and Adolescent Psychiatry, 36(8), 1107-1115.

Appendix A
Questionnaire
1) What are your professional credentials?
2) How many years have you worked with women diagnosed with bulimia nervosa?
3) What theories inform your work with this population?
4) Of the following options, please rate the treatment goals for women suffering from
bulimia nervosa according to relevance, utilizing the following scale.
1 2 3 4 5
not applicable slightly relevant relevant moderately relevant extremely relevant
a) Reducing of binge/purging behaviors
1 2 3 4 5
b) Reducing of body image distortion
1 2 3 4 5
c) Increasing self-esteem
1 2 3 4 5
d) Improving self-regulation
1 2 3 4 5
e) Developing better coping skills
1 2 3 4 5
f) Increasing sense of body-self
1 2 3 4 5
g) Increasing body boundaries
1 2 3 4 5
h) Increasing spontaneity of movement
1 2 3 4 5
Please list other important treatment goals not mentioned above.
5) Among the following to what degree do these themes emerge in treatment for this
population? Please rate according to following scale:
1 2 3 4 5
never rarely sometimes often all the time
a) Control
1 2 3 4 5
b) Depression
1 2 3 4 5
c) Anxiety
1 2 3 4 5
d) Shame
1 2 3 4 5
e) Obsessive thinking
1 2 3 4 5
f) Obsessive behaviors
1 2 3 4 5
g) Sexual trauma
1 2 3 4 5
Please list any themes that emerge in the treatment of women with bulimia nervosa that
were not mentioned above.
6) Please rate to what extent the following movement patterns are characteristic of
women with bulimia nervosa, utilizing the following scale.
1 2 3 4 5
strongly disagree disagree neither agree agree strongly agree
nor disagree
a) Purge position (a c-like curve, a sunken chest and a protrusion of the chin):
1 2 3 4 5
b) Lack of movement in chest:
1 2 3 4 5
c) Rigidity of pelvis:
1 2 3 4 5
d) Primary utilization of peripheral movements:
1 2 3 4 5
e) Difficulty grounding weight
1 2 3 4 5
f) Indirect use of space
1 2 3 4 5
g) Sporadic stop and go movements
1 2 3 4 5
7) Are there other movement patterns not mentioned above that you find characteristic of
this population?
8) Please rate your personal use of the following interventions according to the following
scale:
1 2 3 4 5
never use use moderately use all the time
a) Guided Imagery:
1 2 3 4 5
b) Centering Exercises:
1 2 3 4 5
c) Relaxation techniques
1 2 3 4 5
d) Improvisation
1 2 3 4 5
e) Authentic movement
1 2 3 4 5
f) Bartenieff fundamentals
1 2 3 4 5
g) Props
1 2 3 4 5
9) Are there any specific interventions that you utilize regularly that merit attention? If
yes, please describe.
10) To what extent do you find the following movement interventions effective? Please
rate according to following scale.
1 2 3 4 5
not effective somewhat never use / effective extremely

effective not applicable effective
a) Having the patient pick a hated or disliked part of the body, exaggerating its
size and having them move with this pretend exaggeration.
1 2 3 4 5
b) Self-touch to promote body boundary awareness.
1 2 3 4 5
c) Have the patient take two chairs that she places next to each other leaving
space in between them to represent her perceived width. Then having her verify
and adjust to become aware of potential misevaluation or distortion of reality.
1 2 3 4 5
d) Games such as freeze or red light green light to work on elements of starting
and stopping.
1 2 3 4 5
e) Physicalization (Blanche Evans) used to move an experience instead of talking

about it.
1 2 3 4 5
f) Functional technique (Blanche Evans) an individually catered dance technique

that is used to strengthen specific areas, retrain others and decrease tension in
order to help support mental transformations that occur on a bodily level.
1 2 3 4 5
g) Rehearsal of stress inducing or potentially triggering situations in the

therapeutic session to help prepare patient for real situations.
1 2 3 4 5
h) The use of touches and massage to elicit a trusting relationship between

therapist and patient.
1 2 3 4 5
i) Synchronous breathing between therapist and patient, a dyad of patients or

group of patients.
1 2 3 4 5
j) Having patients roll, lay, etc. on the floor to explore tactile sensations in order
to improve body boundaries.
1 2 3 4 5
k) Exploration of weight utilizing polarities of pushing and pulling either alone or

with a partner.
1 2 3 4 5
Are there any specific techniques/interventions that you have developed and utilized that
have proven themselves effective? If yes, please explain:
11) To what extent do you use transference in the treatment of this population? Please
rate according to the following scale:
1 2 3 4 5
Please describe how you utilize transference of the patient in treatment.
12) To what extent do you use countertransference in the treatment of this population?
Please rate according to the following scale:
1 2 3 4 5
Please describe how you use your countertransference in the treatment of this population.
13) To what extent does working with women suffering from bulimia nervosa affect your
own sense of body-self and body image? Please rate according to the following scale.
1 2 3 4 5
never rarely sometimes more than most of the
often time
14) If this work does affect your body-self and body image, please describe in what ways
it is experienced.
15) Of the following, what methods do you utilize to promote self-preservation? Please
rate from 1 to 12 with 1 being the most important and 12 the least.
- Personal Therapy
- One on one supervision
- Peer supervision
- Group supervision
- Massage therapy
- Authentic movement
- Dance classes
- Yoga
- Martial arts
- Meditation
- Exercise
- Other please provide details:
Appendix B
Recruitment Email
Dear ________,
As a current Master’s candidate in Dance/Movement Therapy at Pratt Institute in
New York, I am conducting research on women suffering from Bulimia Nervosa
as part of my thesis project. I am currently recruiting ADTR’s and other
accredited therapists primarily using movement, with at least 5 years experience
working with this population, to participate in my study. Participation in this
study would include the completion of a questionnaire (completion will take no
more than one hour) including questions on movement qualities, the evaluation of
specific interventions and self-care. Participation might also include a semi-
structured interview to clarify responses to questionnaire and expand on topics of
interest, not to exceed thirty (30) minutes. This interview would be done at the
discretion of the principal investigator via phone or in person depending on
location and availability. Participation in this study is completely voluntary and
no remuneration will be provided. The data being collected will serve to create a
comprehensive treatment manual for dance/movement therapists working with
women suffering from Bulimia nervosa. If you are interested in participation
please respond to this email and I will send you the necessary information to
make an informed decision about participating or not.
Thank you for you time and consideration
Ariele Riboh
Appendix C
Pratt Institute
200 Willoughby Avenue Brooklyn, NY 11205
CONSENT TO PARTICIPATE IN A RESEARCH STUDY
TITLE OF STUDY: Repairing the Broken Mirror: a Theoretical Dance/Movement

Therapy Manual for the Treatment of Women with Bulimia.
RESEARCH STUDY:
I, __________________________________________, have been asked to

participate in a research study under the direction of Ariele Riboh
(Dance/Movement Therapy student - Masters candidate at Pratt Institute).
PURPOSE:
The purpose of this study is to establish a more comprehensive understanding of

eating disorders and characteristics in order to establish more effective modes of
treatment through dance/movement therapy interventions.
DURATION:
Participation in this study will last for no more than 2 hours.
PROCEDURES:
During the course of this study, the following will occur:
• Completion of a questionnaire.
• A 30 minute semi-structured interview
PARTICIPANTS:
There will be 4 to 8 participants this research.
EXCLUSIONS:
I will inform the researcher if any of the following apply to me:

- I am under 18 years of age.
- I have not worked with eating disordered populations.
- I am not a registered dance/movement therapist (ADTR) or licensed creative

art therapist (LCAT) or a credentialed therapist utilizing movement specific
interventions.
- I do not have at least 5 years experience working with this population.
RISK/DISCOMFORTS:
I have been told that the study described above appears to involve no risks or
discomforts known at this time. However there may be risks and discomforts that
are not yet known.
I fully recognize that there are risks that I may be exposed to by volunteering in
this study which are inherent in participating in any study; I understand that I am
not covered by Pratt Institute’s insurance policy for any injury or loss I might
sustain in the course of participating in the study.
CONFIDENTIALITY:
Every effort will be made to maintain the confidentiality of my study records.

Officials of Pratt will be allowed to inspect sections of my research records
related to this study. If the findings from the study are published, I will not be
identified by name. My identity will remain confidential unless law requires
disclosure.
PAYMENT FOR PARTICIPATION:
I have been told that I will receive $____0_____ compensation for my

participation in this study.
RIGHT TO REFUSE OR WITHDRAW:
I understand that my participation is voluntary and I may refuse to participate, or

may discontinue my participation at any time with no adverse consequences. I
also understand that the investigator has the right to withdraw me from the
study at any time.
INDIVIDUAL TO CONTACT:
If I have any questions about my treatment or research procedures I may discuss

them with the principal investigator:
Ariele Riboh, Masters candidate

(608) 345-0002 or ed.databank@gmail.com.
If I have any additional questions about my rights as a research subject, I may

contact:
Vladimir Briller, Ed.D. Chair, IRB (718) 399-4245
SIGNATURE OF PARTICIPANT
I have read this entire form, or it has been read to me, and I understand it
completely. All of my questions regarding this form or this study have been
answered to my complete satisfaction. I agree to participate in this research
study.
Subject Name: ____________________
Signature: __________________________
Date: __________
SIGNATURE OF INVESTIGATOR OR RESPONSIBLE INDIVIDUAL
To the best of my knowledge, the participant,

______________________________, has understood the entire content of the
above consent form, and comprehends the study. The participant’s questions
have been accurately answered to his/her/their complete satisfaction.
Investigator’s Name: ____________________ Signature:

_______________________
Date: ______________
Appendix D
Semi-Structured Interview Text.
These are potential questions that will be used to guide the interview. However the
interview will not be limited to these exact questions. Further questions will be
potentially used for further clarification and exploration of topics that may arise during
the interview.
1) What has your experience been like working with women with bulimia nervosa?
2) Over the years how have you dealt with issues of transference and
countertransference?
3) What methods of self-care do you utilize for self-preservation and to avoid burnout?
4) Given your answers on the questionnaire could you please further explain the
following intervention?
5) What is your goal for treatment when utilizing this specific intervention?
6) How do the patients respond to this intervention?

Appendix E
Table 1
Answers to Questionnaire Concerning DMT Experience of Participants
Question Participant A Participant B Participant C Participant D
1. What are your Registered MA, ADTR, ADTR, LCAT MPS, ADTR,
professional clinical NCC (Licensed ATR-BC,
qualifications? counselor, (National Creative Art LCAT
ADTR, RDT Certified Therapist)
(Drama Counselor)
therapy)
2. How many years 18 17 10 Not answered
have you worked
with women
diagnosed with
bulimia nervosa?
3. Informing Object Chace, Modern Psychoanalytic,
theories? relations, Sullivan, Jung analytic feminist
bioenergetics, perspective,
attachment Chace,
theory, Whitehouse
Jungian, and and Evans
sensori-motor.
4. Goals 1 (not applicable) 2 (slightly relevant) 3 (relevant)
4 (moderately relevant) 5 (extremely relevant)
a) Reducing of 5 5 5 5
binge / purging
behaviors
b) Reduction of 5 5 3 4
body image
distortion
c) Increasing self- 5 5 5 5
esteem
d) Improving self 5 5 4 5
regulation
e) Developing 5 5 4 5
better coping skills
f) Increasing sense 5 5 5 5
of body self
g) Increasing body 5 5 3 4
boundaries
h) Increasing 5 5 4 3
spontaneity of
movement
Other: Increase Experience Understanding Increased
pleasure and feelings- one’s creativity and
comfort in connecting relationship to play.
body, help with the inner food and
manage stress, self, eating,
increase ability expressing increasing
to manage feelings, bodily
relationships, identifying understanding.
increase and
communication understanding
skills. connection
between
discoveries in
treatment and
applicability
in day to day
life.
5. Themes 1 (never) 2 (rarely) 3 (sometimes) 4 (often) 5 (all the time)
a) Control 5 5 4 5
b) Depression 4 5 5 5
c) Anxiety 5 5 4 5
d) Shame 5 5 5 5
e) Obsessive 4 5 3 5
thinking
f) Obsessive 4 5 2 5
behaviors
g) Sexual trauma 4 5 3 4
Other: Dissociation, Fear of Trauma such Inability to
attachment loosing as neglect, experience
issues, control. violence. Self- pleasure.
developmental hatred, self-
trauma, shock doubt, social
trauma and pressure to be
grief-loss. thin.
6. Movement 1 (strongly disagree) 2 (disagree) 3 (neither agree nor disagree)
patterns 4 (agree) 5 (strongly agree)
a) Purge position 4 Responses 3 3
considered
N/A
b) Lack of 5 N/A 4 3
movement in chest
c) Rigidity of 5 N/A 4 3
pelvis
d) Primary 5 N/A 4 5
utilization of
peripheral
movements
e) Difficulty 5 N/A 2 5
grounding weight
f) Indirect use of 4 N/A 4 3
space
g) Sporadic stop 3 N/A 4 3
and go movements
7. Other movement Lack of Explosive Minimal Decreased
patterns: integration movements. movements in lack of body
between upper near reach experience,
and lower space, a lack inability to use
body, agitated of full efforts. body
urgency or experience to
little sense of guide
time, focused actions/choice
directional s/thoughts.
movement,
poor spatial
awareness,
rigid spine,
lack of energy
and connection
to pelvis.
8. Interventions 1 (never use) 2 3 (use moderately) 4 5 (use all the time)
a) Guided imagery 3 1 3 3
b) Centering 5 5 2 4
exercises
c) Relaxation 5 5 2 4
techniques
d) Improvisation 4 5 4 3
e) Authentic 2 1 5 2
movement
f) Bartenieff 2 1 1 1
fundamentals
g) Props 4 4 2 1
9. Other Grounding, Participant Mirroring. Use of basic
interventions used: body chose not to stretching
awareness, respond exercises to
breath work increase
and boundary awareness of
work. body
experience.
10. Effectiveness 1 (not effective) 2 (somewhat effective)
of movement 3 (never use/not applicable) 4 (effective) 5 (extremely effective)
interventions
a) Exaggeration of 3 Participant 3 1
disliked body part chose not to
respond
b) Self touch 3 2 3 4
c) Chairs and body 4 2 3 3
image distortion
d) Freeze, red 4 1 3 3
light/green light
e) Physicalization 5 5 5 3
f) Functional 3 1 5 5
technique
g) Rehearsal 4 2 3 4
h) Touch and 3 1 3 5
massage
i) Synchronous 4 2 3 3
breathing
j) Floor work 4 2 3 3
k) Polarities 4 3 3 2
Other Sculpting Participant Mirroring, Focusing
interventions: feeling states, chose not to walking based
moving in respond meditation, exercises, use
relationship to stretching. of movement
emotions and phrasing.
cognitions,
exploration of
kinesphere
through body
and
visualization.
11. Use of 1 (never use) 2 3 (use moderately) 4 5 (use all the time)
transference
Scores: 5 5 4 N/A
Other: Transference Explores Used to Didn’t use due
provides therapeutically support to short-term
diagnostic actively and client’s setting
information, passively. process.
guides
interventions.
12. Use of 1 (never use) 2 3 (use moderately) 4 5 (use all the time)
countertransference
Scores: 4 Participant 4 5
chose not to
respond
Other: Also provides Participant Gather To understand
information chose not to information: metaphors of
about client. respond what does the the patient’s
client want me experience
to know? and to
Used to understand
understand the useful and non
client’s useful
experience. responses
within the
therapeutic
relationship.
13. Effect of work 1 (never) 2 (rarely) 3 (sometimes)
on body–self and 4 (more than often) 5 (most of the time)
body image
Scores: 4 2 3 3
14. What effects? Awareness of Participant More aware of Eating used as
effects on self chose not to personal a defense is
of cultural respond relationship to heightened.
images of food and
beauty eating.
Awareness of
cultural ideals
of beauty on
self.
15. Methods used Personal One on one Personal Personal
for self- therapy, one- supervision, therapy, one- therapy, one
preservation on-one peer on-one on one
supervision, supervision, supervision, supervision,
massages group group group
therapy, supervision, supervision, supervision,
authentic personal meditation, meditation,
movement, therapy. authentic exercise.
meditation, and movement,
exercise. social life.

Dance/movement Therapy and Bulimia Nervosa

Încărcat de

Informații document

Titlu original

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

Dance/movement Therapy and Bulimia Nervosa

Încărcat de

Drepturi de autor:

Formate disponibile

REPAIRING THE BROKEN MIRROR: A THEORETICAL DANCE/MOVEMENT

THERAPY MANUAL FOR THE TREATMENT OF WOMEN WITH BULIMIA

© 2009 Ariele L. Riboh

REPAIRING THE BROKEN MIRROR: A THEORETICAL DANCE/MOVEMENT

THERAPY MANUAL FOR THE TREATMENT OF WOMEN WITH BULIMIA

Received and approved:

______________________________________ Date _____________________

______________________________________ Date _____________________

History of Eating Disorders

DMT Theoretical Practices

Table E1. Answers to Questionnaire Concerning DMT Experience of Participants.

dance/movement therapy appears to be an appropriate and perhaps more relevant

movement characteristics; specific movement interventions; the therapist’s use of

transference and countertransference, and the self-care methods used by dance/movement

came to the actual practice of dance/movement therapy (DMT).

Treatment of Women with Bulimia.

Today, the incidence of eating disorders is reaching concerning levels. According

1988 and 1993.

disorders, including psychodynamic, action-oriented, cognitive-behavioral, interpersonal,

self-psychology, structural family therapy, developmental, feminist, pharmacological,

study aims towards the compilation of a pilot treatment manual presenting

History of Eating Disorders

since been explored.

Freud originally attributed eating disorders to “neurotic conflicts about sexuality”

(Maine, 2009, p. 7) he viewed these conflicts as involving “oral incorporative

unconscious sexual conflict and subsequent compromise formation. (¶ 4)

In the 1960s, behavioral treatment emerged as the popular choice of treatment.

Today, according to Vanderlinden (2008), cognitive behavioral therapy (CBT) remains

the treatment of choice and is highly recommended by most “evidence-based treatment

“dysfunctional scheme of evaluation” (p. 329) is central to the maintenance of eating

these dysfunctional beliefs directly.

disorders linking their origin to primary biological abnormalities, gastrointestinal

problems, disruptions of various cerebral components, an inability to negotiate critical

can be attributed to environmental and socio-cultural influences. However, specific

responsible factors have yet to be determined.

According to Krantz (1999), “Eating disorders refer to disturbances of eating

behaviors and body-image distortions with underlying psychodynamic, cultural, and

Defining Eating Disorders

According to Davis (2009), eating disorders are primarily psychological disorders

consumption and because, as food and eating is symbolized, a variety of medical,

body-distortion. The main symptoms of BN are recurrent episodes of binging and

purging by self-induced vomiting, abuse of laxatives, and vigorous exercise (Krantz,

According to the American Psychiatric Association Diagnostic and Statistical

starvation. Such symptoms may be expressed as “depressed mood, social withdrawal,

irritability, insomnia and diminished interest in sex” (DSM-IV-TR, 2000, p. 585).

thinking, have also been identified as symptoms.

“repeated episodes of binge eating followed by inappropriate compensatory behaviors”

are very similar in their psychological development and symptomology. Binging

behavior is characteristically done in secrecy and is associated with intense feelings of

triggered by dysphoric mood states, interpersonal stressors, intense hunger following

criteria for mood disorders, anxiety disorders, and personality disorders.

focus on the female population.

Now that a preliminary understanding of the symptomology of this disorder has

etiology; however, there is “growing acknowledgement that neurobiological

vulnerabilities make a substantial contribution to the pathogenesis of anorexia nervosa

neurological disturbances associated with eating disorders to neuropeptide dysregulation.

Neuropeptides are molecules involved in message transmission by neurons in the

brain/body communication process. Hence, neuropeptide dysregulation can directly affect

tying abnormal levels of serotonin (5-HT), an essential neurotransmitter, to “appetite

persist after recovery.

There is approximately a 50 to 80% genetic contribution to liability accounted for

in schizophrenia and bipolar disorder, suggesting that anorexia nervosa and

bulimia nervosa may be as influenced as disorders traditionally viewed as

__________________ Date _

__________________ Date _