EGO-STATE THERAPY IN THE TREATMENT OF A COMPLEX EATING DISORDER

North East London Mental Health Care Trust

Abstract:

           This report describes the treatment of a woman with a diagnosis of binge eating disorder and a history of bingeing and periods of starvation throughout adolescence and adulthood. She had sought a number of different therapies, but not really benefited from any of them. She felt confused about herself and did not have a sense of her identity. She had recognized there were parts of herself that seemed separate from each other. Egostate therapy with hypnosis helped her to understand the cause of her compulsive bingeing. This was followed by the hypnotic affect bridge which enabled her to access another child part of herself concerned with a fear of starvation and abandonment, and wanting to remain ‘solid’ but not ‘fat’. These phases of therapy produced great improvement in her eating behaviours, which she had not experienced before. By accessing the ego-states, she was able to start an inner communication, and make cognitive and emotional changes. This was reinforced later with cognitive therapy, from which she had not gained much benefit previously. The importance of combining these therapeutic approaches is discussed. Key words: ego-states, dissociation, eating disorder, cognitive change Introduction Mrs Z, a married woman of 42 years of age, was initially referred to the psychology department of a psychiatric hospital for treatment of her binge eating, which had caused her to be overweight.

       Since the age of 14 she had had episodes of bingeing, which were followed by many months of starving, such that she lost 3 stone in as many months at one stage of her life. She had never abused laxatives or vomited, though she said she had been tempted. She had sought psychotherapy before and had a course of Gestalt therapy, which she said enabled her to access the ‘addict’ inside her, but just knowing this was not helpful to her. She had spent three years seeing a therapist at a pastoral foundation and had not found this beneficial. She had also been to Eating Anonymous and similarly found no benefit. Mrs Z commented that during the Gestalt therapy she realized she had ‘unresolved issues’ which she could not identify and therefore were not addressed. She said she needed to look into this further. Con Hyp 20.3_3rd revised 10/9/03 10:34 am Page 165,166 Degun-Mather

Present circumstances:

       Mrs Z felt the need for a close friend or confidante and was clearly lonely. Although she and her husband had a harmonious relationship, she felt he did not have the same sexual desire as she had. They had no children (by mutual agreement). Her husband had been made redundant six years previously and she had taken a job working for a charity, which she enjoyed. The couple had also pursued common interests. There was no evidence of clinical depression or anxiety in Mrs Z. She and her husband had sufficient money to go on holiday and enjoy themselves, but these occasions led to her bingeing. Background history Mrs Z’s childhood was very unhappy. She was the only child of her adoptive parents. She had been rescued at six weeks old, after having been abandoned by her biological mother. She was admitted to hospital in a state of malnutrition. When she was fit enough, she was discharged into the care of Social Services, and then adopted by her present parents.

          Mrs Z described her parents as lacking in understanding, love and affection. Her father was very critical and prone to violent outbursts. He was an ex-prisoner of war in World War II, and had suffered a ‘mental breakdown’ as a result of his wartime experiences. Mrs Z considered he was permanently confused and angry and would not allow her to express her opinions or her emotions. Her father only related to her when she stopped eating, telling her that she would not want to experience real starvation as he had during his stay in a concentration camp. Her mother was shy, and clearly had difficulties dealing with her father, and did not spend much time with her daughter.

        There were periods in her childhood when Mrs Z was looked after by her grandmother, whom she also felt did not understand her. Her comment on her childhood was ‘nobody related to me, nor showed me where I fitted into the scheme of things’. Mrs Z was quite content in her school life until the age of 14, when she was raped by a boy she knew well. She told no one of this, and started bingeing. After leaving school, Mrs Z took various jobs but was ‘desperate’ to marry. At the age of 25 she married a man 10 years older and a divorcee. They agreed to have no children. Mrs Z said she was not in a position to offer a child any affection, having been deprived of it herself. During her adult life Mrs Z had been able to establish relationships and make friends, but none of these were close enough to be a confidante. Thus she had feelings of loneliness from time to time. Otherwise she presented as a friendly, intelligent person with a sense of humour. Her underlying feelings are well conveyed in a written account she presented on first psychological assessment (see below).

      She felt there were two parts of her. One was the ‘higher self’ who was well focused, in control and able to cope with difficulties. The other part was the ‘lower self’ who was out of control, disorganized and unable to cope. This part did all the eating. Being fat gave her security as it was a barrier and protection against male attention and against others making demands on her. She remained unassertive but safe. Con Hyp 20.3_3rd revised 10/9/03 10:34 am Page 166 Ego-state therapy in the treatment of a complex eating disorder 167 In Mrs Z’s written account of herself it became clearer how very distressed she was: My strongest and most persistent negative feeling is confusion – about myself; my relationship with the world and how I fit in. What am I? – and where does that which isn’t me begin and end? – I have always been searching for an identity – a defined outline … but I have become a blob. My parents and Nan did not serve any purpose for me … maybe I was there to provide them with something … but I was never sure what … I could not put into words this huge thing I knew was missing, that I so desperately wanted and needed … my physical and spiritual existence always felt perilously fragile. If my fat had a voice it would scream and shriek in rage because it is very angry fat. It really does not like anybody much – only me … When I was thin I liked it, I had nothing else to speak for me, so I found I was amazingly good at speaking for myself… but I was never happy … that I felt more valid just because I looked more valid … The only way out of this dilemma is to find myself, and where I belong … When I am valid, worthwhile and comfortable living within my outer shell … I will be strong enough to take care of myself, and negotiate on my own behalf … I will be neither manipulator nor manipulated … I will be hungry and afraid, but I will nurture myself. When that time comes, I will make my own choices and go with what seems right and comfortable. Those choices will extend to the size of the body I live in … it will serve no hidden purposes … It will be just what it is – a convenient earthly home for a far more precious spirit.

Therapy Phase one

        Initially a cognitive-behavioural approach was adopted, since Mrs Z had never tried this, and it has been shown to be effective for binge eating disorder (Fairburn 1995). Mrs Z responded to this approach initially, and was able to go on holiday with her husband and eat normally without bingeing for the first time. However, on return she started bingeing again. She commented that she could do nothing to prevent the innerurge to binge, and she could only describe it as the ‘addict’ part of her. At this stage in therapy, it seemed appropriate to consider ego-state therapy with hypnosis as the best option for her. Rationale and commencement of ego-state therapy Ego-state theory and therapy has been well described by John and Helen Watkins (1997).

          For those less familiar with the concept of ego-states, the following is a brief summary. Our experiences become categorized as we develop through childhood and attempt to find meaning and purpose in our lives. Certain feelings, thoughts, perceptions and behaviours bond together as they relate to particular experiences. These separate clusters of thoughts, feelings, and behaviours relating to different experiences and contexts are known as ego-states. According to Watkins and Watkins (1997: 25) ‘An ego-state may be defined as an organized system of behaviour and experience whose elements are bound together by some common principle, and which is separated from other such states by a boundary that is more or less permeable.  This theory has originated from Pierre Janet’s view of dissociation. Janet (1907) believed that there were ‘systems of ideas’ which were not ‘in association’ with other ideas in the personality.  This process of dissociation is seen as part of normal, healthy development. However,in the event of exposure to traumas, ego-states may emerge which have partial or total Con Hyp 20.3_3rd revised 10/9/03 10:34 am Page 167 168 Degun-Mather amnesic barriers between them. Thus the person may have difficulty shifting from one ego-state to another, or even may shift without conscious awareness. This can lead to internal conflicts between the ego-states and more dissociation between them.

          Ego-state therapy involves activation of the dissociated ego-states, in order to facilitate co-consciousness and communication between these ego-states. Thus the partial or total amnesic barriers can be broken to create inner harmony and more integration in the personality. This procedure can easily be carried out through hypnosis (Torem 1987; 1989).

        When ego-state therapy was suggested to Mrs Z, she related to it well. The first session of hypnosis was for the sole purpose of relaxation in her special, safe place. She also learned self-hypnosis. In the second session of hypnosis, the ego-states were activated and communication started. The aim was to find ways of meeting the emotional needs of the separate parts in a more adaptive way and thus to reduce the conflict.

          Permission was sought in hypnosis to speak to the ‘addict self’. Mrs Z responded in the affirmative through ideo-motor signalling. The ‘addict self’ emerged and announced herself as ‘powerful and destructive – I live inside Mrs Z because she’s helpless, pathetic and cannot cope. I punish her for being helpless – it keeps her dependent on me. If she is not dependent I won’t have anywhere to live. I am a parasite; I feed on her, and she gives me somewhere to live.’ The dialogue in hypnosis then continued as follows: Therapist: Are you happy with this? Addict: It’s not satisfactory, but it is safe and comfortable. I am not really powerful but Mrs Z thinks I am. In fact I am more pathetic than she is. I won’t let her have a life. I need her more than she needs me. I want to keep her helpless, it’s best. I can fool her and manipulate her. She makes me feel powerful, and I don’t want her to know that I am not brave enough to be on my own. I have to teach her a lesson when she tries to get rid of me, but I don’t actually help her at all. I keep her down. I am an excuse. I am too scared to leave her. I need security, and she is too scared to cope and take risks. 

Phase two:

       Three months later, Mrs Z reported a different problem, although still related to food. She said she always had to carry some food in her bag when she went out anywhere, otherwise Con Hyp 20.3_3rd revised 10/9/03 10:34 am Page 169 170 Degun-Mather she would panic. She did not feel compelled to eat the food; it was just in case she felt hungry. She said she felt she might cease to exist if she allowed herself to get hungry and starve. She did not believe this was anything to do with the ‘addict self’, whom she felt  had gone. This was not a compulsion to eat; it was a fear of not existing any more due to starving. She thought it was related to her having nearly died at six weeks old due to neglect. She also considered this was reinforced by the comments from her father about his own experience of starvation in the war. She stated that on one occasion in the past she had visited a lay hypnotist who had used hypnotic age regression, which led Mrs Z to this conclusion. 

        Although she could not have any memories for what happened to her at six weeks old, her acquired knowledge of this fact could have had an impact on her. Nevertheless it was necessary to explore the significance and meaning of these fears and behaviours. Another hypnotic intervention that seemed appropriate was the affect bridge (Watkins 1971). This would enable her to go back in time to the period when she first experienced this fear and panic, and thus find the cause. In the next hypnotic session, using the affect bridge, Mrs Z was asked to imagine herself in a recent situation, feeling hungry and having no food available, and to build up her feeling of panic. 

        Mrs Z was offered our group therapy for binge eating disorders, which has a cognitive-behavioural format with hypnosis. Here she would have the support of fellow sufferers, as well as the chance to come to terms with her unfortunate circumstances, so she did not need her  ‘anaesthetic’. She readily joined the group. She made dramatic progress over 12 weeks of group sessions. During this time she said she realized that she had believed her illness was a punishment and that she was not meant to survive as a child. So now she was getting what she deserved. Suddenly she understood during the group sessions that this was a form of self-abuse; the adult was punishing the inner child, who had survived. What she needed to do was to nurture and comfort the child. Cognitive and emotional changes were made between the two egostates, when she once more paid attention to these ‘inner voices’. 

        Summary and comments on the phases of therapy The first hypnotic intervention using ego-state therapy revealed the nature of Mrs Z’s addiction to bingeing and becoming obese. Fat was for protection, and a barrier against unwanted attention from men, and unwanted demands of others. It was also a way of expressing her feelings (particularly anger) through her size. Later she discovered that food itself was a substitute for lack of love too. It was surprising when her fear of starvation emerged after the demise of the ‘addict self’, since she had written in her first account that when she was thin, she had been assertive, and felt and looked ‘valid’ to others.   

        Hypnosis with ego-state therapy played a major role in dismissing the ‘addict self’, who no longer served a purpose. She was then able to access the inner child and scan her childhood and teenage years and to parent the inner hurt child. Resolving the issues of the past in this way led her to seek solutions for the present problems and the future. 

        Con Hyp 20.3_3rd revised 10/9/03 10:34 am Page 172 Ego-state therapy in the treatment of a complex eating disorder 173 Mrs Z was able to benefit rapidly from cognitive therapy, which she pursued after the hypnotic interventions. Previously cognitive therapy did not have much impact, perhaps because she did not hear the ‘inner voices’ of the ‘addict self’ and the inner desperate child. Watkins and Watkins (1997) have commented that cognitive therapy addresses the thinking patterns of which the person is aware, but cannot probe deeper to an unconscious, emotional level of which the person is not aware (Watkins and Watkins 1997: 158). Ego-state therapy can achieve this, and cognitive and emotional changes take place. Mrs Z had not previously been aware of her inner child, and she commented that she had never realized she could do her own inner parenting. The lapse into bingeing after several years was resolved when she once more realized the inner conflict between the ego-states. 

References:

Fairburn C (1995) Overcoming Binge Eating. New York: Basic.

Janet P (1907) The Major Symptoms of Hysteria. New York: Macmillan.

Torem MS (1987) Ego-state therapy for eating disorders. American Journal of Clinical Hypnosis

30(2): 94–103.

Torem MS (1989) Ego-state hypnotherapy for dissociative eating disorders. Hypnos 16: 52–63.

Watkins JG (1971) The Affect Bridge: A hypno-analytic technique. International Journal of

Clinical and Experimental Hypnosis 19: 21–7.

Watkins JG, Watkins HH (1997) Ego-State – Theory and Therapy. New York: W.W. Norton and Co.

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