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CONTROL IN BULIMIC EXPERIENCE AT THE BEGINNING AND THE END OF TREATMENT
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Elena Faccio, Sabrina Cipolletta, Diego Romaioli, Sara Ruiba
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University of Padua, Padua, Italy |
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Abstract
This qualitative research examines the question of
control within bulimic experience and how it varies from the beginning to the
end of the therapy. We used two self-referral tools (self-definition and
self-characterisation) with 42 patients, 24 at the beginning and 18 at the end
of the therapy. A comparison between the two groups suggested that patients at
the beginning of the therapy anticipated that the solution of the problem was improving
the ability for individual control while patient ending the therapy more easily
broke free from the confines of the control/lack of control dichotomy.
Keywords: Bulimia, control, eating disorders,
personal construct psychology, self-narratives
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INTRODUCTION
Alimentary control is not only an important issue in contemporary
society, but is also a key theme in restrictive or repeated vomiting behaviour.
That is why control is a construct used in many theoretical writings on eating
disorders. Anorexia nervosa is frequently described as a syndrome of
pathological self-control (Bruch, 1962; Crisp, 1972; Slade, 1982; Lask &
Bryant-Waugh, 1993). Many authors pointed out the presence of a battle for
keeping control within the family context (Bruch, 1962; Ma, 2008; Ugazio, 1998,
Castiglioni & Faccio, 2010). Control behaviour and attitudes are prominent in
clinical assessment tests, for example, the Body
Checking Questionnaire (Reas, Whisenhunt, Netemeyer, & Williamson, 2002)
to assess control behaviour, the Body
Image Automatic Thought Questionnaire (Cash, Lewis, & Keeton, 1987),
which analyses automatic and obsessive thoughts about food, or the Appearance
Schemas Inventory Revised (Cash, Melnyk, & Hrabosky, 2004), which measures
body image investment. However a clear definition of the construct of ‘control’
is not always given in the literature, either with regard to the original
theory, which proposes it, or with regard to the methodology used to analyse
it.
The term ‘control’ can occasionally
refer to a behaviour, a compulsion, a cognitive attitude about themselves,
others, and situations, or to a modality to construe and replicate experiences.
This last definition drives into the field of Kelly’s personal construct psychology,
which many authors consider a particularly fruitful and appropriate way of
studying eating disorders (Mottram, 1985; Jarman, Smith, & Walsh, 1997;
Winter & Button, 2010). In this
perspective constructs related to eating and weight best allow eating disorders
patients to predict and control their world. Consequently, the more important
weight is, the more “resistant to change” the person is (Crisp & Fransella,
1972; Fransella & Crisp, 1970). Other constructs are strictly linked to
control. Constriction allows persons to avoid anxiety, which derives from
unpredictable situations: when persons are not able to deal with the
uncertainty and the variability deriving from an area of their life, due to not
having control on it (for instance, in the relational field) they contrast the
lack of control avoiding the situation (Button, 2005; Winter & Button,
2010).
According to Mottram
(1985) “anorexics [have] a prevalence of segmented and monolithic structures
when compared to non-clinical groups, characterised by a prevalence of
articulated structures” (p 291). Button (1983, 1985, 1990), investigating
self-constructs involved in anorexia nervosa, concluded that clinical subjects
manifest more extreme constructs than non-clinical ones and emphasised the need
to articulate the relationship between ‘rigidity of constructs’ and existent
difficulties with food (whether psychological or of a general nature). Indeed, even
if much evidence can be found in the literature supporting a polarisation of
construct systems associated with psychopathology, this does not mean that
health can be associated with immense flexibility and change. It rather depends
on the stability and continuity of self. Extremely unfavourable and favourable
judgements of self might make a person more vulnerable to psychological disorder
(Cipolletta,
2011; Faccio,
Centomo, & Mininni, 2011). Moreover, “self-perception seems to be closely
linked to the perceptions of others, so that extreme construing may also extend
to the perception of others, such as parents and other important figures”
(Button, 1993, p.215).
At a
first sight anorexics might also be characterised by tight construing and
bulimics by loose construing (Faccio, Castiglioni, Veronese, Mosolo, &
Bell, 2011), nevertheless the research findings are controversial about this point:
tight constructs have been already observed in an anorexic sample (Mottram,
1985), restrained eaters (Neimeyer & Khouzam, 1985) and female students
showing disordered eating (Heesacker & Neimeyer, 1990), but not in a mixed
sample of anorexic and bulimic students (Batty & Hall, 1986). However, Dimčović and
Winter (2011) found greater severity of eating disorder in those bulimic
clients whose construing was tighter and more polarised. Researches indicate
more one-dimensional construing in anorexics than in bulimics and the use of
fewer constructs in anorexics than in normal controls (Button, 1993).
Russ-Eysenschenk (1998)
has concluded that eating disorders patients exhibit greater construct
integration and lower differentiation. Comparing two clinical groups (low and
high eating disorder), the author observed that the high eating-disordered
group tended to associate a weight increase with a consistent and implicit
change in their personal, interpersonal and vocational relationships. Thus radical changes in those very
important areas, which together make up a sense of personal identity, would be
associated with control or loss of control (Romaioli, Faccio, & Salvini,
2008).
RESEARCH AIM AND HYPOTHESES
The present research aimed to
identify constructs linked to control in bulimic experience, assuming the
existence of two opposite phases: control and lack of control. We wanted to
explore the role of these elements in maintaining an identity system, and the
destabilisation of the sense of worth and meaning in personal identity implied
by a change in weight, if such change means ‘loss of control’.
In line with the results of previous
research, we hypothesised that the control/lack of control constructs might be
essential in the bulimic experience, since they tend to organise thoughts and
anticipations in a dominant way. From a Kellian perspective the dominant
modality of construing experience in bulimic subjects can be described as the
effect of persistent attempts to face and resolve situations or experiences
anticipated as uncontrollable. This is accomplished using the only repertoire
of behaviour and anticipations (in the field of food management) considered
appropriate, because they have already been used many times, and are believed
practical and effective (Button, 1993). The bulimic experience is characterised
by a cyclical alternation of periods of extreme dietary restrictions (during
which control functions, operating on self and relationships, predominate) and
bingeing episodes (characterised by feelings of powerlessness and
inevitability). These are often followed by compensatory measures such as
vomiting, use of laxatives, intense physical activity or food restrictions.
Herman and Polivy (1975) were amongst the first to define this process as a
form of dichotomous cognitive restriction based on the ‘all or nothing’
principle. “Every deviation, however minor, from the rigid norms which the
individual has set for themselves, every transgression of the veto
placed on particular kinds of food, gives rise to the phenomenon of alimentary
inversion” (Apfeldorfer, 1996, p. 22) and leads to bingeing episodes. These
moments, so feared and at the same time desired, seem to go beyond the
willpower of the individual, who often feels torn, and the episodes of binge
eating are experienced both as proof of failure and moments of complete
abandonment and freedom to enjoy at one and the same time.
We can identify two superordinate constructs:
‘lack of control’, which deals with the self-narrations and self-perceptions regarding
psychological mechanisms involved in excessive eating, and ‘control’ which
deals with those involved in the
mastering of psychological processes typical of the restrictive phase. In the
first system, lack of control, persons feel distanced from their core
self-constructions and their uncontrolled actions, do not recognise themselves
in the actions carried out - bingeing - and avoid taking responsibility by not
acknowledging them (“I didn’t do that”, “I couldn’t help myself”), so that they
feel guilty. The second system, the control one, brings the self closer to how people
wish to be (“I always want to be in control”, “from tomorrow I’ll succeed and
everything will be different”) and they stubbornly cling to an action plan (the
compensatory or restrictive behaviours) destined to fail. Keeping to a diet
becomes a means to control and resolve every problematic or equivocal life
situation. Becoming more important in the hierarchical system of constructs,
this alternating between control-lack
of control turns into a constellatory loop: every uncertain, inept experience or action will be perceived
and described as a replication of the dichotomous situation of “control-lack of
control”, thus preventing any kind of progress and movement being made.
This hypothesis may be viewed in the
light of Fransella’s (1970) suggestion that the way that symptoms are organised
eventually become more central components in the construction system of
identity (Winter, 1983; Ng, 2002): “Even an obviously invalid part of
a construction system may be preferable to the void of anxiety which might be
caused by its elimination” (Kelly, 1955, p. 831). Feixas and Sałl (2004) agree with
this analysis: in their studies of dilemmas and cognitive conflicts preserving
a symptomatology serves to maintain identity coherence and relational stability,
thus making change threatening.
On the basis of these premises, the present study explored how people
described themselves in relation to control and how their self narratives
changed at the beginning and at the end of therapy. Specifically, we
investigated:
| 1. | The
modalities of anticipation and replication of the bulimic experience, their implications, and the role
of control in maintaining personal identity.
| | 2. | Individual
‘beyond problem’ anticipations, how people beginning therapy might visualise a
different reality to their present one (themselves beyond problem). It was anticipated
that they would not have seen themselves freed of the problem (expecting
phrases like “I can’t imagine what it’s going to be like” or “I don’t know how
to answer this”). The opportunity for re-narration, offered by the therapy, was
predicted to facilitate alternative solutions to those offered by control-lack
of control dichotomy.
| | 3. | Narrative
differences between the two groups of people at the beginning and at the end of
therapy. Would the self narratives of people at the end of the therapy have supported the hypothesis of a greater
flexibility and fluidity compared to those of the people beginning the therapy?
| | 4. | Whether the self-referral tools were useful to an
exploration and illumination of differences amongst the participants. |
METHOD
Participants
42 people (41 females and one male,
all between 18 and 40 years old) undergoing psycho-dynamic psychotherapy for
bulimia-related disorders (23 of whom also presented with vomiting symptoms)
took part in the research. The participants were recruited from two institutes
in Northern Italy: the Clinical Institute for Anorexia and Bulimia in Mestre
and the Napoleon Park Villa Care Centre in Preganziol (Treviso).
Inclusion criteria were that the diagnosis
provided by the healthcare institution was ‘bulimia nervosa’, and no other
eating or psychopathological disorder, that the Body Mass Index (BMI) was
between 18 and 23, corresponding to the normal weight bulimic patients, and
that the patients were at the beginning or at the end of their first treatment.
The decision to exclude patients
with double diagnosis, with minor psychopathological comorbidity and with more
than one psychotherapeutical treatment, was restrictively applied in order to minimise
the risk of including individuals with potential different addiction problems,
so as to avoid the production of ‘spurious’ narratives, which could be
influenced also by previous therapies.
Participants were informed of the
research aims (“an investigation of whether the problems of bulimia and
identity systems might be interrelated”) and methodology (using “two
self-referral tools” and by “writing a short story about your experiences”).
They gave their informed consent and were assured that their real names would
not be used and that any information given would be treated in accordance with
confidentiality laws. APA guidelines on how to conduct research using human
subjects were followed.
Participants were divided into two groups: the
first composed of 24 people beginning their therapy (12 from Mestre and 12 from
Treviso); the second of 18 people (9 coming
from the Mestre centre and 9 from the Treviso one) who had finished their therapy.
Only subjects who had specifically sought treatment from a healthcare
institution for an eating disorder were included in the research; in addition, only patients at the beginning
of the treatment (at maximum one month after admission) and patients at the end
of the therapy were recruited at one month after conclusion of psychotherapy.
Treatments duration was minimum nine months, maximum one year with weekly
sessions.
The socio-demographic
characteristics of the subjects in the two groups were as
similar as possible.
Data collection
The research aimed to understand
people in terms of autobiographical ‘story systems’ (Mair, 1987), in which
individuals speak both as narrators and actors, therefore two self-report tools
were used. The first of these, the self-characterisation, although less
well-known than repertory grids, is perhaps the technique that best allows
freedom of expression, and meets Kelly’s criterion that the best way to find
out what other people mean is to listen to the words they use. Mair (1987),
paraphrasing the fundamental postulate of personal construct psychology, suggests
that people’s actions are psychologically governed by the stories they
experience and by the stories they tell. Crites (1975) also maintains that
anticipations are expressed by means of story telling and by the descriptions of
the causes and consequences of the events. Fireman and McVay (2002) state: “We narrate
our lives and live the narratives that result” (p.167).
Self-characterisation was used in a modified version: both groups were
asked to write “a story about a man or a woman who had problems with food” (in problem situation) and a story about a man or a woman
“who however had succeeded in overcoming them” (beyond problem situation). This
invitation to describe themselves “as if” they were a character in a parallel story enabled participants to
reveal “a theory” about themselves. Following the principles of Vaihinger’s (1924) ‘as if’ technique, they were given the opportunity
to fantasise beyond the problem (Merton,
1949), thus tackling the transition from the problem through to solution.
The second
tool used to explore the identity system and its structure was a set of self-descriptions, which
included a modified Twenty Statement Test, first developed by Kuhn and
McFarland (1954) and successively revised by Giovannini (1979) and
Lorenzi-Cioldi (1996). Participants were asked to write down 10 adjectives or
short sentences describing themselves in two situations, “who am I when I don’t control
myself” and “who am I when I control myself”.
The tools were completed in an
individual interview session, in presence of the researcher.
Data
analysis
While one researcher
interviewed all the participants, two independent judges analysed the narrative
texts without being aware of the origins and to which group the texts referred
to. The level of inter-rater agreement, measured by Cohen’s kappa coefficient,
was 0.87. For the doubtful cases, the two raters had mutually agreed the final
version here presented.
The narrative texts
were analysed to extrapolate topic subgroups (clusters) which could facilitate
the identification of the most common and recurrent areas of meaning.
The
characteristics of the self-definitions related to the two situations (elements
to which personal constructs were applied) “who am I when I don’t control myself”
and “who am I when I control myself” were compared and their organisation (the
relationship between the constructs, the dimensions and the dominant themes)
was explored. We used three-phasic analysis, consisting in the
observation of the type, number, and relationship between elements and
constructs (inter-constructs), traditionally used to analyse repertory grids (Armezzani,
Grimaldi, & Pezzullo, 2003; Kelly 1955), and theme analysis to identify
inter-constructs arising from the pattern of self-constructs in the lack of
control scenario, and within personal constructs in the control scenario. We
followed Landfield’s guidelines on pyramiding interviews (Landfield, 1971; Landfield
& Epting, 1987) to examine the dimensions extrapolated from the two
scenarios. Assuming that constructs first elicited are product
attributes, which are followed by consequences and finally become end states
or values, we used the laddering procedure (Hinkle, 2010; Bannister & Mair,
1968) to discover the implications governing hierarchical systems within the
constructs.
Two kinds
of analysis of the self-characterisations allowed
the identification of individual processes of anticipation and validation of
one’s own self: first, how the texts were structured and organised, and second, how the anticipation
processes functioned and what was their extension. Kelly’s (1955) classic
interpretative model consisting in tackling the main themes, organisations and
perspectives in the text was used, and then the process of anticipation was analysed
(focusing on sequences of events, repeated transitions and the prevalent style
of construing).
The two ‘stories’
suggested to the participants to write (one concerning “a man or a woman who
has had problems with food” and the other concerning “a man or a woman who
however succeeded in overcoming them”) were treated as elements to which they
could apply their own personal constructs:
self in problem and self beyond problem. Using a series of traditional
techniques of interpretation, the intention was to compare stories in order to
measure narrative similarities or changes. Because of the modifications to the
task asked from the participants, i.e. transferring transitional passages from
the in problem story to the beyond problem story, it became essential to
analyse those relevant sentences (in terms of narrative style) which might
reveal modalities of anticipation, and the opening and closing statements. A
careful analysis of the syntax and style of the stories enabled the
identification of the main transitions, roles and identities. The anticipations
of self beyond problem were compared with those of self in problem ones,
retracing the core matrix. We investigated whether participants’ processes were
characterised by loose, flexible, or propositional constructs, and the
structure of their construct system noting the frequency of incidental,
constellatory or pre-emptive constructs.
Finally,
the self-characterisations of the beginning therapy group were compared with
those of the ending therapy group and the self descriptions in the lack of control situation with the self-characterisation
in problem situation. The aim
of this last analysis was to compare the two self-referral techniques and to test
the presence of the construction processes involved in the two systems of lack
of control (prevalence of transitions of blame, constriction and loose
constructs) and control (mostly transition of hostility, incidental and tight
constructs).
RESULTS
The range of meaning in bulimic experience
It has been clearly identified a contrasting of polarities
of constructs in the self-definitions and in the stories of self in problem.
In the stories of self beyond problem anticipations seem to be less structured,
with vaguer and less defined frameworks, particularly in the stories of the ending
therapy group.
Three main ‘inter-constructs’ were extrapolated from
the self-descriptions, superimposed on the “who I am when I’m in control” and
“who I am when I lose control” (table 1). They represent three main fields of meaning, together forming a core role:
the field of ability (weak/insecure vs.
strong/secure), the relationship field (isolated/distant/free vs. extrovert/lonely/controlled) and the
moral judgement field (mistaken/ashamed of myself vs. perfect/proud of myself).
Table 1: Fields of meaning found in the
self-definitions
LACK
OF CONTROL
“who am I when I don’t control myself” | IN
CONTROL
“who am I when I am in control” | weak/
lacking confidence
“incapable”, “frozen”, “still”, “I waste
time”, “weak”, “lack of confidence”; “empty” | strong/confident
“strong”, “powerful”, “capable”, “confident”,
“proactive”, “someone who plans”, “makes choices”, “commits to something”, “a
doer ”, “confronts situations”, “fulfilled” | without
limits / unrestrained
“lost”, “excessive”, “without limits”,
“irrational”, “thoughtless”, “vulnerable”, “fragile”, “liberal”, “without
restraints”, “nobody can take away the only thing I have” | strict/controlled
“rational”, “strict”, “hard”, “motionless”,
“bound/ obligated”, “artificial”, “others control me”, “others want to take
away the only thing I have” | wrong/
shy
“rotten”, “selfish”, “liar”, “bad”, “I’m
shy”, “it isn’t me”, “wrong”, “i deny myself”, “dirty”, “ugly”, “careless”,
“a beast”, “a fury”, “not worthy”, “an addict”, “mistrusted”, “disappointed” | perfect/
proud
“perfect”, “bold”, “proud of myself”,
“satisfied”, “I’m my ideal”, “I love myself”, “clean”, “careful”, “deserving
love”, “good” | isolated/
distant
“set apart from others”, “other people’s
opinions don’t count”, “I isolate myself”, “lonely”, “distant”, “abandoned” | extrovert/
lonely
“I go along with others”, “extrovert”,
“always available”, “altruistic”, “pleasant”, “nice”, “kind”, “I can love as
well”, “sweet and feminine”, “I’m involved with others”, “isolated”,
“lonely”, “uninvolved” |
Although core
constructs were organised at opposite extremes, both in the ‘self-control’ and
the ‘lack of control’ situations, their implicit meanings were similar: people
compared themselves with others to validate their expectations. Whereas
isolation was the end result of wishing to avoid relationships with others in
the lack of control situation, in the in control situation avoiding others
resulted from feeling involved or obligated within relationships (participants described
themselves as ”false” and “obligated” because “others control me”). Moral
judgement regarding their behaviour (“wrong” vs. “correct”) was the criteria
the participants used for measuring how distant/close they were to others, and
led to “the right” to be loved and esteemed by others as just “reward”. This
same construct also applies to more or less adhering to a diet and to
self-control (in other fields besides food as well). As predicted, the
participants felt “capable”, “sure” and “worthy of being loved” when they felt
in control and when they were not in control they became “powerless”, “weak”
and “unworthy”.
The same themes were in self-characterisations,
both in the self in problem stories and in the self beyond problem ones (table 2). The participants recounted a
reality filled with problems described only in terms of their relationship with
food: the “story of a woman or a man who has had problems with food”, “her life
style is body-centered and food-centered (…) not only is she a safety net but
also a truly stable personality”, “food had become a daily obsession”, “she was
always famished and needed to fill her stomach”.
Table 2: Main constructs from self-characterisations
INTO-PROBLEM
SELF
“a story of a woman or a man who has had
problems with food” | BEYOND-PROBLEM
SELF
“who
however has succeeded in overcoming them” |
| INTER-CONSTRUCTS | Me
and food
(isolation)
Stable identity: “her life style is
body-centered and food-centered [...] a real, true, stable identity”; “she
lives in a chaotic world, designed to control her life”
Abandoned child: “she is growing up feeling
she was abandoned”; “she was a very lonely child, abandoned”
The world’s lies: “the ideal world is made of
lies”; “she has hidden her feelings [...] behind a mask of self-control”.
Social prostitute: “she always asked herself
what the others wanted of her”; “she didn’t know who she was”, “she seemed a
social prostitute”; “in her opinion life was what others wanted her to be” | Dimensions | Me
and others
(relationship)
New and real life: “a new
life, based on trust”; “the previous girl didn’t know about life”
Aware woman: “she’s a woman who doesn’t hide
her fragility, she’s able to face her fear”; “now it’s her who decides”;
“she’s starting to feel more a woman”; “it’s the time to make adult choices”
Confidence: “today she’s a more mature and
aware woman”; “the anger’s no longer there”.
Relationship: “she’s learning to love,
without relying on others’ wishes [...] thanks to reciprocity!”; “she allowed
love into her life”
| | IMPLICATIONS | Lack
of ability
“She’s left it to chance”; “this fear of
growing up has held her back a long time”; “food was often an anaesthetic for
difficulties” | Ability | Ability
“She’ll succeed in taking back control of her
life”; “she’s a woman able to live her life in the first person” | Isolation
“She was stand-offish, she isolated herself,
she spent hours by herself [...] away from everyone, distant even from
herself”; “she was a lonely girl, but with an affected solitude” | Relationship | Relationship
“She feels that she’s free [...] without
fearing being overpowered / hurt”; “she’s starting to live with others” | Shame
“She didnt’t think she deserved happiness”;
“she was never on one level”; “deep guilt feelings accompanied A” | Moral judgement | Worth
“Now she can exist without others’ approval”;
“now she’s learning to defend herself, to carve out her life, because she
deserves it” |
Others, often meaning other family members, were
perceived as oppressive, demanding, compelling, who take without giving and
judge without understanding (“her brother became stronger by weakening and
denying L.”, “she didn’t feel she was understood”, “nobody ever asked her what
was wrong”, “she could never confide in anybody”, “she believed others
overestimated her”, “her mother kept her under surveillance“). In these stories
others “abandon”, don’t pay attention, don’t love “unconditionally” (“there was
no room for her in her mother’s life”, “she always got less food than her
brother”, “she felt abandoned”, “she was left to her own devices”).
This interpretation is very similar
to Button’s (2005) theory that invalidation is a central experience in the
stories of people with eating disorders. He states that “people with eating
disorders are deficient in their ability to construe other people: they have
difficulties in understanding, controlling or interacting with people. Their
constructs about other people may be very limited or they may have restricted
expectations of other people, the resulting effect of which is that they are
unable to successfully engage in other than limited relationship with others.
Restriction in social activity, staying at home more, keeping to familiar
places” (p.4), all derive from lack of interest in relationships and at the
same time perpetuate it.
In the absence of an external
perspective with which to confirm their worth and personality, their
self-esteem entirely depends on their own self-discipline. It is no coincidence
that the expectations of those who had left their problems behind (those
telling the story of the character “who however succeeded in overcoming them”) were
anchored in their relationship with others, in dialogue and exchange, and thus
all references to food disappeared. The central themes of these stories were faith,
and, above all, “love”, sometimes rediscovered (“her father learnt to believe
in her”), sometimes discovered for the first time (“the love of a man with who
you can plan a life together”) and others again imagined (“calmer
relationships”, “confidence in others”).
Individual “beyond problem” expectations
Analysing the differences in the
ways that expectations and future outcomes were experienced by bulimics in the
two groups at the beginning and at the end of the treatment, and in the two situations
(into and beyond problem), it was possible to observe that narrative
constructions of the group at the end of treatment were fixed, in some cases, and
fluid and open to redefinition, in others. There was a major difference in the
matrices, in the ways that roles were construed in these stories. In many of
the stories characters had singular names and personalities, and existed in
relational constructs, which permit interdependence (or a more distributed dependence).
Many self beyond problem accounts, although differing in terms of how identity
was defined (“a woman who doesn’t hide her vulnerability, but who ‘fesses up’”,
“a much more aware and mature woman” who has succeeded in “taking control of
her life”, “who wants to live her life making first person choices” “without
relying on the approval of others”), were similar, constructs were
constellatory and punctuation was more structured than that used by the group
at the beginning of the therapy.
We can hypothesise that the bulimic
constructs of the beginning therapy group were nurtured by expectation
belonging to both the lack of control self and the in control self. The wide-ranging
and lacking structures of the lack of control self were largely sustained by guilty
periods (it is “others’ fault”, “lack of love”, “being abandoned” which “causes
bulimic crises”, other people who “over- impose” or who lend “their support” to
needs which make these young people feel “crushed” or “overwhelmed” ). Hostile
expectations sustained the more stringent self in control processes. In these
cases people continually were looking for confirmation of their own
preconceptions (“you can’t trust” others, because “they abandon”, “they always
take without ever giving in return”, “they suffocate with their demands”, “they
don’t understand”). “Happiness isn’t possible” because individual attitudes are
considered “all wrong”. Isolation becomes the only choice remaining (“because
others want to take away the only thing I have” (food), “they take away all
your love”, they’re not interested”, “they do nothing but make demands”). Both
in control and lack of control modes confirm the implicit and controlling role
of the bulimia construct in the self perception of the person.
Narrative
differences between the two groups
The self beyond problem narratives in
the group beginning therapy (table 3)
contained expectations characteristic of the bulimic way of thinking concerning
control, particularly in the relational field. In their hypothetical future, an
individual problematic situation was seen as an expectation that “food is a
substitute for love” (“false hunger”,
“avoid to be filled”, “nourishment when feeling abandoned”, “can love make you
feel as full?”) or it was converted to “others as substitutes” (“love is
rediscovered through others”, and it is others who “get [them] to believe in
themselves”, “encourage trust” and “teach [them]”). On the contrary, when food was perceived as dependence on/overwhelmed by others (“antidote”,
“safety net”, “safety valve”, “escape route” to/ from problems, “frustrations”
and “other people’s needs and expectations”), alternative solutions were
centred around independence from others
(“first love yourself” and “defend your personal space” and “personal gains no
matter what”). The future was seen in an opposite way, but preserved a similar
structure.
In the narratives of the group at
the end of the therapy there was found an increasing range of alternative
constructs. An awareness and a reading of their own past life made up of
“gradual deformities”, mistaken attitudes, longed-for ideals (“vowing to look
at things in a different way”, “to better […] understand others and improve”,
“to understand other people’s needs”, “choosing for [your]self”) pervaded these
stories. This view was fundamental to the “decision to change“ and developed
alongside a renewed possibility to plan and act different things, if they worked,
and to confront problem situations.
Table 3: Self beyond-problem narratives of
the two groups of participants
| BEGINNING THERAPY GROUP | ENDING THERAPY GROUP | | TRANSITION:
INTO-PROBLEM SELF → BEYOND-PROBLEM SELF | GUILT:
“doctors [...] and [...] friends helped her”; “trust came when she travelled”
HOSTILITY: “she learned that you have to do
as others do: first think for yourself, then for others”
AGGRESSIVENESS: “reconstructing the blocks in
her life, she understood", "choosing ion the first person" | GUILT: “she dismissed the pain and allowed
love to enter”; “her father’s love helped her”
AGGRESSIVENESS/ANXIETY: “so she understood”
AGGRESSIVENESS: “she decided to observe her
world and the world around her, but in a different way”; “to understand
others [...] and to improve herself” |
The
usefulness of the self reports
Regarding the choice of self-report
tools, it is possible to state that self-definitions produced larger and more
understandable data, compared to those normally produced with provided
definitions, and ensured greater transparency and flexibility. The range of
meanings and implications found with the two tools coincided: in both cases the
most common themes were ability/lack of ability, relationship/isolation and
shame/worth (see tables 1 and 2).
The self-characterisation, which
allows the imagination to go beyond the problem, can be used not just for
feedback, but also as a module to interpret and potentialise individual and
relational resources, by making the individual responsible for undertaking a
new initiative or activity, whether creatively or in reaction to circumstances.
Perceiving
and bringing to a conclusion allows people to build up narrated realities which
may trap them (Dimaggio, Semerari, 2001), but which may also suggest them
alternative interpretations while preserving the continuity of their meanings (Neimeyer, 2000).
CONCLUSIONS
The results
of this research suggest that it is possible to reconstruct a very complex
phenomenon which is implied in the bulimic experience departing from a matrix
of expectations and experiences of control and excessive self-monitoring,
mostly in a protected situation such as psychotherapy is. The protagonists of
this change reconstruct things in different ways, out of the control/lack of
control blind alley. These people have succeeded in changing their own systems
of meanings, modifying their properties and making them more transparent. These
changes are breaks in the interpretative mould, which allows the individual to
understand that experience should be subordinate to their own anticipations
rather than a one-dimensional interpretation of reality. This finding confirms Button’s
consideration of constriction (2005) as the most useful personal construct
concept in understanding eating disorders; the restriction of the perceptive
field is also an attempt to make life more manageable, in contrast to the lack
of control and invalidation experienced in relationships with other people (Winter
et al., 2010). On the other hand a construction process characterised by
dilation is typical for people raising their perceptual field in order to
organise it at a more comprehensive level, a condition that we could observe in
narratives at the end of therapy. At that point, construing processes were less
tight and less polarised, confirming what Dimčović and Winter (2011) observed comparing
people with great and little severity (or absence) of eating disorder.
Additionally, the outcomes of this
research suggest that therapists, as facilitators of possible new versions of
self (Mair, 1987), can play an important role
in helping other people to reconstrue their stories. The
self-characterisation, prompted by the beyond problem situation, can be a very
sensitive tool for documenting and undertaking possible directional changes.
This technique, following Grice’s (1975) definitions regarding the principles
of cooperation which govern people’s conversations (quality, quantity,
relevance and narrative style), appears able to sustain and promote people’s
ability to get into the role of different actors and tell their stories as
characters in different stories (Dimaggio & Semerari, 2001). Interactions
between the therapist and the patient thus become a “two heads are better than
one” interpretation of new imagined scenarios and possible future plans (Mair, 1987). Suggestions
to change the narrative genre of individual biographies may offer viable alternatives and permit new
stories to be told. Additionally, negotiating a meta-narration can permit
an already expected version of the self, which has not yet been experienced
because it is considered incompatible with the main narrative system, to be included
and analysed (Dimaggio & Semerari, 2001).
To sum up, the
results of the research largely confirm the hypotheses being examined and still
they leave room for further investigation. For example, the analysis pointed
out that adhering to a diet and maintaining self-control (in other situations
besides food, too) become a personal moral judgement. As a result, controlling oneself
makes the person feel “capable”, “secure” and “worth loving” whereas losing
control makes him/her become “powerless”, “weak” and “unworthy”. The same
principles govern the relationships with others, construed in terms of distance/proximity,
which makes self-esteem a “right”, derived from others’ love and respect. We
investigated whether individual attributes in the self-esteem realm had similar
extreme values: positive self-esteem and self-worth coincided with periods of
self-control and negative ones with perceived lack of control. Thus self-esteem
depended on the situation and the phase in which the person was. This ‘situational’
interpretation of the meanings and value of individual identity should help researchers
to understand why clinical groups are characterised by “a greater negativity of
self-construing”. Requests for therapy occur when individuals try to resist to
loss of control (which has damaged their sense of identity), and therefore
recognise their more negative self-representation (Button, 1990). It has also
been investigated how other means of identity and individual worth constructs
are arranged, once a person’s worth and value are no longer organised by and
dependant on an ideal control as, according to the results of our research,
happens at the end of therapy. In this regard, the research might be carried
out by evaluating psychotherapeutic changes also through a measure of
self-esteem, as suggested by Button (1990), and repertory grids might be useful
for this aim. Rethinking recovery from eating disorders may also open the way for
new treatments (McIver, McGartland, & O'Halloran, 2009).
With regard to the methodology
adopted, the self-definitions might be used also to investigate another hypothesis.
Since self-definitions correspond to constructs elicitated by the persons, the
same descriptions might be used as constructs on a repertory grid in order to
analyse the domain of personal relationships. This would enable us to draw up
both consistent and inconsistent solutions by using the imaginative ways persons
perceive themselves when compared to how they construe other people and
relationships. In fact, as researchers and psychotherapists alike know,
analysing expectations and outcomes in the field of interpersonal experiences
represents an essential component of the therapy, since relationships with
others in such cases are very often accompanied by difficulties which range
from lack of understanding to control and denial of experience.
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| | | | | | DECLARATION OF CONFLICTING INTERESTS
The authors
declared no conflicts of interest with respect to the authorship and/or publication
of this article.
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FUNDING
The
authors received no financial support for the research and/or authorship of
this article.
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ABOUT
THE
AUTHORS
Elena Faccio is assistant professor in the
Department of Applied Psychology at the University of Padua in Padua, Italy.
Sabrina Cipolletta, PhD, is assistant
professor in the Department of General Psychology at the University of Padua in
Padua, Italy.
Diego Romaioli, PhD, is adjunct professor in
the Faculty of Psychology at the University of Padua in Padua, Italy.
Sara Ruiba is psychologist and psychotherapist
in Padua, Italy. | |
Elena Faccio
Diego Romaioli
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Sabrina Cipolletta
Sara Ruiba |
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REFERENCE
Faccio,
E., Cipolletta, S., Romaioli, D., Ruiba, S. (2011). Control in bulimic experience at the beginning and the end of therapy.
Personal
Construct Theory & Practice, 8, 24-37, 2011
(Retrieved from http://www.pcp-net.org/journal/pctp11/faccio11.html)
Contact:
Sabrina Cipolletta, University of Padua,
Department of General Psychology, Via Venezia 8, 35131 Padova, Italy
Email: sabrina.cipolletta@unipd.it
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Received: 21 March
2011 – Accepted: 30 August 2011 –
Published: 25 September 2011
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