Can Sally,1 a 32-year old struggling with anorexia also be a responsible student nurse on an eating disorder unit? The answer is never under-estimate the power of denial.2
The very qualities that masked Sally’s obsessive thinking about fat and the next meal were just what the job called for—perfectionism, double-checking, and steely discipline. Sally’s psychotherapist, Lauren Lazar Stern, would compare her patient’s work life in the hospital to being a nurse in a war zone. In Stern’s words, “Sally’s job was to walk in armed and try to help the patients and avoid getting entangled in their emotions.” However, for Sally, this was not a conscious choice. While doing rounds, she was unconsciously coveting her own patients’ symptomatology.
To comprehend how committed Sally was to keeping her anorexic pledge at the time, one has only to read her own rules about restricting food, penned in her journal; so horrific they could read straight out of Orwell’s 1984:
- You must be a size 0/S/XS, and the size 0/S/XS is NEVER allowed to be tight. A size 0/S/XS should be your usual; nothing special. 00 is a self esteem booster.
- Your hip bones MUST stick out. Even when you’re stuffed or bloated, they must always protrude. If they rub against clothing and scab up, even better.
Clearly, nursing on the eating disorder (or “ED”) unit had become a hazardous line of work, triggering Sally to avoid meals altogether with colleagues and even her fiancé, Jason. But who was looking? As Sally tells us:
ED patients are sick but they’re high-functioning. In some ways they are also very low-functioning: the fact is we are slowly killing ourselves every day.
A pattern of denial
When Sally first meets Stern, she admits that her coping mechanism has been to drop weight, but that since college it’s gotten “out of control.” If anyone suspects she has a problem, she just turns it around, making them feel ashamed for even harboring the thought. Sally confides:
I basically try to make it so awkward they change the subject and turn it around on them: I can’t believe you think I’m unhealthy; it’s a natural part of the major I’m in. I can’t believe you think I’m mentally ill …
About to marry and have a family with the only real witness to her self-starvation, Sally tells Stern she is “scared to death.” But Jason either skillfully or unwittingly downplays her disordered eating behaviors. Sally admits:
Jason knows, but not 100%, and tries to make light of it. He doesn’t know I’m seeking treatment. I go in and out of spurts; then I relapse again. During this past relapse he made a comment: You’re getting too thin. I blamed it on being “vegan.”
Now Sally’s guilt and shame are mounting, and she no longer wants to cheat on Jason with Ed.3 It’s time to separate from, disagree with and disobey ED, her eating disorder. With just weeks to Sally’s wedding, Stern sets to work.
In treatment, followed by reinforcement
Self-discovery for Sally begins with Eye Movement Desensitization and Reprocessing (EMDR) therapy. EMDR is a physiologically-based therapy that helps a person identify, desensitize and reprocess a distressing memory. EMDR seems to have a direct effect on the way that the brain processes information. Following a successful EMDR session, a person will frequently remember the images, smells or sounds of a distressing event but no longer suffer from the feelings associated with it.
An early session exposes the truth about Sally’s nuclear family negatively impacting on her self-view. Sally learns that she has been meeting her mother’s unhealthy standards of beauty, because on the verge of womanhood, she became her mother’s rival. Sally recalls:
Mom got me big T-shirts to hide my breasts. She made me feel ashamed of my size.
Thrilled now with EMDR’s desensitization of this distressing memory, Sally still genuinely denies her body dysmorphia.4 In order to gauge the extent of her body hatred and distortion, Stern has Sally write a letter to her body and encourages her to journal. Yet it is only when Stern does a pencil body tracing that Sally is stunned to see that she still resembles her 12-year-old self. This is the turning point that changes Sally’s negative self-view significantly. She falls in love with food again, revises her envy of stick-thin women and enjoys compliments on her looks.
But as is often the case, self-doubts resurface, especially in the morning as she dresses for work. Clothing no longer hangs loosely off her frame. So Sally asks for a second tracing to confirm that she is OK. This tracing combined with talk therapy reassures her that getting comfortable in her new body takes time and that she’s on track.
The Healing Dreamscape method
Relapse is all too common in the treatment of anorexia. This is why Lauren Lazar Stern takes a multi-disciplinary approach—bringing art therapy, talk therapy and EMDR together to build on each other. She then reinforces recovery with a post-therapy resource we call “prescriptive photomontage.”
When Sally starts eating and feeling more human and a part of the world; that is, when distressing memories (or her mother’s comments) no longer trigger her, Stern switches gears, and Nancy Gershman enters the picture as Sally’s prescriptive artist.
Prescriptive art is a relatively new means of arts intervention – involving process and product – for individuals in psychological distress. It is often combined with other therapies such as psychotherapy, EMDR and expressive art therapy. During the information-gathering stage, the prescriptive artist probes for uplifting or redemptive memories and themes that have surfaced in previous therapies. During the brainstorming stage, the prescriptive artist consults with her client to reframe and re-contextualize these events and memories into a work of art—a meaning-laden composition that elevates their epic story, affirming their self-worth and highlighting its universal themes. Moreover, as fine art, its multi-layered nature lends itself well to sharing, providing opportunities for meaningful interactions and secondary healing.
In the work of Nancy Gershman, the end product is a digital photomontage called a Healing Dreamscape. Upon close examination, you can see Sally’s Dreamscape is a hybrid object, digitally constructed from many photos—both Sally’s and other photographers’—whose imagery Gershman uses to replicate memories for which Sally has no personal photos. It is a tangible visualization of a preferred future,5 a portrait from which Sally (and Jason) will draw strength and comfort. More importantly, the Healing Dreamscape is designed to motivate active work and accountability as Sally follows through on her intentions: that is, not to relapse. Perhaps the best part of the method is the deep connection that forms between client and prescriptive artist as they arrive at those ah-ha moments together.
The creation of Sally’s prescriptive photomontage
|Sally’s prescriptive photomontage by Nancy Gershman
Note: For confidentiality purposes, the faces of Sally and Jason have been digitally altered to protect their identities.
By the time Sally weds Jason and returns from her honeymoon, she’s ready to make her Dreamscape. Sally speaks with prescriptive artist Nancy Gershman for the first time over the phone. The first thing Gershman asks is: What’s been gelling for you in therapy? What’s been happening back at home? Sally shares that Jason is encouraging her to vary her diet:
Jason doesn’t eat the same kind of foods I eat. I eat nutritiously-dense foods, not 100% junk food. I’ll say to him: I’m making this really delicious tofu dish, and he’ll laugh, saying: Why would I waste any of the space in my stomach?
Gershman senses some tension as Sally talks about her and her husband’s desire to become “more mutually supportive of each other’s healthy habits.” Sally elaborates:
I have issues, but Jason has his own issues. He’s a heavy smoker trying to quit. I tell him, I’m not the only one bringing toxicity into this relationship.
Sally says she works hard to overcome her fear of certain foods. But while she’s the change agent, Jason appears stuck:
Everybody has their own baggage they bring to the relationship. You wouldn’t be a human being if you didn’t bring something negative to a relationship. I feel Jason is less of a work in progress than I am. I feel a person is a work in progress until you die.
The situation seems to call for a Promissory Dreamscape. This type of visualization works quite well when two parties are encouraged to reach for the same goal, even if their actions are not symmetrical. In Sally’s case, Gershman will want to explore how much positive influence a husband and wife—each with their own dietary preferences and food choices—can have on one another. Given the Dreamscape’s playful nature and blend of fantasy and reality, Gershman searches for a non-threatening way the Dreamscape can coax healthy competition between Sally and Jason, without putting either partner at risk.
Sally and her prescriptive artist brainstorm about an irresistible proposition that can turn Jason into that “work in progress.” Sally is asked: What’s his favorite sport?
Jason loves to fish. If there is some way for that to be a high impact workout …
Sally’s joking of course, but her remark is spot on. Gershman needs more confirmation about how much Jason likes exercise, and she gets her answer:
Jason’s still smoking. We have a treadmill. I told him I don’t want it to be a towel rack.
What about a fisherman-turned-action figure? This time Sally is asked: What does Jason want from you?
I really like to cook and bake: stir fry, Asian. But Jason wants me to eat what I cook for him: baked ziti, lasagna, heavy Italian casseroles. He wants me to be comfortable with my body.
So Jason, who loathes exercise and a healthy diet, doesn’t perceive himself at risk like his wife. A clear inequity, but there’s a workaround; the couple shares a great sense of humor. Here is where Gershman makes the leap that Jason’s lackluster opinion of exercise could be jump-started by X-treme angling. Perhaps Jason could be an action figure fisherman with multiple arms that are engaged in cardio, strength training … and a gesture of tenderness?
For purposes of meaning-making, Sally and Jason’s commitment must be seen in realistic, yet epic terms. So in the Dreamscape, Gershman includes a formerly negative trigger for Sally—lasagna. After being reprocessed in EMDR as a calorie booster and a comfort food, lasagna is no longer a trigger. Therefore the artist incorporates the two props—lasagna and the maki roll—because they hold special meaning for Jason and Sally. The outfits they’re wearing are pulled from personal photos, evocative of good times: fishing for Jason and their wedding for Sally. Gershman sets Sally and Jason against a rolling sea background, Ulyssian enough to bring out the heroism in their character, providing a new place for a fresh start. The expression on their faces is meant to captivate. Sally comments:
My face is of pure happiness. Jason’s is of pure enjoyment. He’s eating a BBQ sandwich at our engagement party. My picture was taken right after we took our vows. You can see my eyes are really shiny from my tears. Perfect!
In a gesture recalling a bride and groom feeding each other mouthfuls of cake, Sally offers the maki roll to her superhero. Jason, with grace and gentleness, keeps one arm fish-free so he can feed a morsel of lasagna to his wife. It becomes the ultimate teachable moment:
This was Jason and me in our relationship with each other; what I want it to be and what it should continue to be in the future. The feeling that we are nourishing each other in different ways …. He’s feeding me rich food, something I was very afraid of. I am giving him the same thing, giving his body what it needs.
Sally’s Promissory Dreamscape transports the newlyweds to a different cognitive plane where they can look more allegorically and metaphorically at their unique situation instead of literally and judgmentally. It encourages Sally to pick out all the salient points and connections made in treatment, while letting her and her husband explore new roles within their marriage. All Sally has to do is take a bite of lasagna from her husband’s hand. If she can, it’s the achievement Sally’s been dreaming of since she walked into Stern’s office.
Emboldened by her preferred future
Leonard Shlain writes in Art & Physics about how visionary art can alert us to a grand new conceptual shift that is about to occur in the way we perceive the world. Stern believes Healing Dreamscapes perform a similar role as they positively trigger the recovering anorexic.4 The power of prescriptive art lies in the fact that the observed and the observer are one and the same. Sally is meeting and exceeding expectations both inside and outside the Dreamscape. Her reprocessed fear of food and Jason’s new regard for healthy living is reinforced in their Dreamscape, precipitating only positive insights and feelings. Sally explains:
Looking at the picture reminds me of the mindset I was in when I began treatment …. I hardly recognize her! It reminds me of the promises I made on my wedding day because my head is from our wedding pictures. It also reminds me of the courage it took to begin treatment and how exciting it was to share my commitment with Nancy [Gershman].
The versatility of the Dreamscapeis another advantage. Sally’s digital photomontage—in one form or another—is always in her mind’s eye. An 8×10 photographic print hangs framed above the TV where Jason and Sally see it every day. Sally owns two other versions, one that sits on her desktop and another resized to fit her wallet. Sally illustrates how this works for her:
I always have my wallet and the small version [of the Dreamscape] inside. If it’s lunchtime and I’m getting anxiety about the impending meal, I pull it out and say: Be healthy. I can do this. It’s O.K. I try and think positively and say calming phrases to myself. I think about Jason. I tell myself: This is your husband. If you were him, how would you feel if you saw me losing weight, worried, sad, asking how long is my wife going to be alive doing this?
Once the self no longer includes distortions, it’s thrilling for patients to see a healthy, thriving version of themselves in their Dreamscape. Sally writes:
I am very happy. I actually feel like I have a personality again. When I was very focused on being as thin as possible, I wanted to disappear. And that’s not really me. I like to have a presence and be seen and heard. I realized how much energy I lacked and saw my personality was muted by the disorder.
Many patients, like Sally, share their Healing Dreamscape with family:
I told them it was exactly what I needed: something visual I could always keep around. A huge part is being stuck in my own mind, intellectualizing all the time, not having tangible manifestations of my feelings. This, I can touch, and it’s a reminder—especially for anxious people—not to shut off those feelings of anxiety.
This is not to say there won’t be any more bumps in the road, but now Sally’s coping strategies are ingrained. If disappointments crop up, the Dreamscape is one of many resources she can turn to, calling up a meaningful reminder of triumph at a time of distress. Digitally, the Dreamscape can even be altered in the future so that it grows along with Sally. In its next incarnation, conceivably it could offer encouragement as Sally moves into motherhood and beyond.
The authors would like to acknowledge the courageous steps Stern’s patient Sally has taken and continues to take to ensure a good life with her husband, family and close friends, free of anorexia nervosa.
- Not her real name. Also, for confidentiality purposes, the faces of Sally and Jason in their Healing Dreamscape have been digitally altered to protect their identities.
- Thomas Holbrook, a psychiatrist specializing in eating disorders didn’t seek treatment for his own eating disorder until the 6’-foot tall doctor weighed in at 135 lbs. and his own patient became afraid for his health.
- Ed is a reference to the self-critical Super Ego that slowly takes over the mind with dangerous and unhealthy impulses regarding food. It is discussed in Schaefer and Rutledge’s 2004 breakout book, Life Without Ed: How One Woman Declared Independence and How You Can Too. New York: McGraw Hill Books.
- The affected person has a severely distorted image of their bodies, seeing obesity in the mirror where others see skin and bones. Onset of symptoms generally occurs in adolescence or early adulthood, where most personal criticism of one’s own appearance usually begins.
- The term “preferred future” refers to a narrative collaboratively defined by the client and a guide, describing the client’s ideal future, outside of illness or trauma. See White, M. & Epston, D. (1990). Narrative means to therapeutic ends. New York: W. W. Norton
Holbrook, T. (2000). Making Weight: Men’s Conflicts with Food, Weight, Shape and Appearance. Carlsbad, CA: Gürze.
Schaefer, J. & Rutledge, T. (2004). Life Without Ed: How One Woman Declared Independence and How You Can Too. New York: McGraw Hill Books.
Shlain, L. (1993) Art & Physics: Parallel Visions in Space, Time, and Light. New York, NY: Harper Perennial Press.
White, M. & Epston, D. (1990). Narrative Means to Therapeutic Ends. New York: W. W. Norton.
NANCY GERSHMAN is a prescriptive artist who partners with the mental health community to help individuals grappling with loss, regrets, unresolved issues and ruptured plans. The mission of her studio, Art For Your Sake is to work narratively with clients, co-creating a prescriptive photomontage as a means of collecting stories, healing broken hearts, and opening dialogue about black and white thinking. The Healing Memory Project—conceived by Gershman and Stern as a safeguard against relapse for ED patients in recovery—is one such collaboration. In 2008-9, Gershman had a solo show at The Loyola University Museum of Art in Chicago. Her work in bereavement and complicated grief has been featured in Advance for Nurses, Annals of American Psychotherapy and Living with Loss magazine. This is Gershman’s third article for Hektoen International. Contact Nancy to arrange a collaboration or talk.
LAUREN LAZAR STERN, MA, ATR-BC, LPC is a master’s level, board certified art psychotherapist and a licensed professional counselor. For the past 25 years she has specialized in working with girls and women suffering from eating disorders and body image distortion. Stern obtained her art therapy degree from Hahnemann Medical College and Hospital in Philadelphia in 1979 and was specially selected to participate in an internship at the Hampstead Child Therapy Clinic in London where Anna Freud was Director. In addition to expressive arts techniques, she is a certified practitioner of Eye Movement Desensitization and Reprocessing (EMDR), which she uses for the treatment of eating disorders, trauma, and other conditions. Stern is the author of The Slender Trap: A Food and Body Workbook, a step-by-step manual designed to help individuals who may have eating disorders take the next steps towards treatment and recovery. For more information, visit Stern’s website: www.laurenlazarstern.com.