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Nourishment:  Drumming with an Anorexic Patient

by Bonnie D. Harr, MSN, MS, RN

  Several times in my life, my professional work in women's health has led me to patients with anorexia nervosa.  It is a profoundly challenging, and sometimes frightening disease for a care-giver to help any patient manage!  For the patient, anorexia seems to be an ever-increasing, isolating nightmare that leads to obsessions with food, calories, and exercise, while insidiously engendering self-loathing.  The tentacles of anorexia are both physical and psychological in nature.  The disease takes a toll on the body of the one held captive in its grip, while impacting families, friendships, and all relationships, including the one a patient has with him or herself.  

The etiology of anorexia is unknown.  Many interesting and compelling theories exist as to the variables that may be causative factors.  My direct experience with patients teaches me that anorexia is, among many other possible and probable things, most definitely a disease of self-perception!  No matter how thin the person becomes, she always FEELS fat. Often, accompanying this feeling of being fat is a de-identified sense of self, loss of purpose and focus on all else but food, and a loss of meaningfulness in living.  
  As the disease advances, the anorexic patient needs to feel power to avoid feeling the powerlessness of being totally out of control.  At times, this can lead the patient to create whirlwinds of chaos for those individuals closest to her. She creates the experiences  that cause family members and friends to worry about her enough ,to stop all they are doing and focus on her alone; she derives a sense of pleasure at being able to activate their emergency response, and by virtue of her willfulness as well as the harrowing nature of the disease, will intentionally activate it over and over again, or because of serious medical compromise will find herself in need of activating it.  At other times, the patient TAKES control by engaging in covert and secretive self-destructive behaviors, such as binging and purging.   In the absence of a multidisciplinary form of sustained therapy, the ultimate end to this protracted and convoluted disease is organ compromise, organ failure and/or suicide. The disease literally consumes the patient as the patient consumes less and less food.  
While serving as part of a multidisciplinary treatment team  and counseling with an anorexic young woman in her early 20's, three manifesting aspects of the disease led me to hypothesize that the drum just might be one effective management tool in the armamentarium of all that makes up an extensive and intensive treatment plan.  The first such aspect is the patient's natural desire to be in motion; activity equates to weight loss; drumming is motion! The second manifestation is a longing for acceptance and guidance even though there is often a simultaneous refusal of social interactions; drumming can be either a group or individual activity.  Finally, the third is the attraction to and use of ritual. From ancient times to this present now, rituals flow out from drumming and are as unique and meaningful as a drummer will create / design them to be.
  Beyond my recognition of all three of the above mentioned patient manifestations, as a counselor, I was also aware -- both intellectually and intuitively -- of the drum's power as a communication tool.  When in the right hands, head, heart and spirit, I KNOW the drum is capable of bridging any communication-generated chasm or linguistic barrier that might be in play. Knowing also that feeding and talking are both oral activities that humans engage in, I could stretch the idea a bit to suspect that when food and eating patterns are disrupted and distorted, so too are words!  I saw this in my young patient. I felt certain that the mental blocks and disjointed thoughts she frequently exhibited could be transformed and given expression on the canvas of the drumhead.  Her continued revealing of her plight, her feeling of being connected, and her general well-being (brought about by an activity that engaged her and intrigued her) was more than important.  It was vital.
And so, I intentionally restructured our sessions together, to include drumming.  I waited for a day when the patient came in with low energy and high frustration, knowing my wait would not be long.  The medications that had been prescribed for her often made her drowsy during our fifty minute sessions.  If she wasn't talking, she would drift into a light sleep, easily, at the sound of my voice.  I determined that I would first use the ocean drum, and if my patient fell asleep, I would allow her to sleep for our time together and gently awaken her in time to regroup before leaving.  Because insomnia was one of her more taxing secondary problems, I felt if this worked, we could get an ocean drum or a rain-stick for her and allow her to self-induce sleep.  While my next statement is overly simplistic, it worked!  
Over several months, at similar times, this intervention was repeated; eventually the patient requested an ocean drum, and one was ordered for her.  Her self-report was that she built ocean drumming into her "night-time routine" and it "helped relax" her "like white noise might, but better, because I have to use my mind to keep the beads from crashing around harshly, rather than just being mindless about it as a noise in the background". (On an Ethical Note: The patient was not charged for any of the sessions where she slept!  It was not a sleep study - it was a hunch that paid off in the end, as she was much more functional when she had a good night's sleep, than when she didn't.  I believe this "little trial" as I call it, has implications for studies related to sleep and/or night-time rituals.)
As we went along, I began to structure ten minutes of drumming together into our shared times.  I pre-set an intention for the drumming to occur at those times when the patient lost her train of thought, or felt she just didn't "have anything to say".  Although tentative at first, as we drummed together to find the way to what is inexpressible in words, she began to effectively use the drum as her voice!  After a while, I could literally stop my drumming, and she would continue on. Sometimes she played with tears flowing; at other times she had a distant and far-off gaze, entranced in her thoughts and challenges, or possibly in the drumming "zone" that is a peaceful place of uncommon rest. Those of you who have facilitated circles will understand when I say that she raged, became remorseful, explained, cajoled, denied, and confessed on the surface of the drum.  Each drumming interlude was cause for debriefing.  I noted that following our/her drumming, she tended to stretch further and reach down deeper into the pools of swirling darkness that characterize anorexia.  I would work to bring cognitive light into the dark places. . .
At another strategic point in her journey, where the anorexia was somewhat under control, but binging behavior was more frequent, and the patient was hard-pressed to keep herself from frequent purging, I introduced the buffalo drum and mallet as an instrument for keeping both hands engaged in a small and confined space. At her initiative, we discussed such things as Pavlov's dogs and conditioned responses, substitution of a non-harmful activity for a harmful one, object cathexis and more.  Together we designed a plan for those times when she felt the urge to purge, based in part on her reaching for the drum.  Since purging is the most private of activities, having a hand-held drum -- like the buffalo drum nearby, was easily accomplished.  
The patient predictably had more difficulty with this aspect of interventional drumming.  The binge-purge cycle of the disease is a bear gone wild!  That having been said, the intervention provided some control for the patient, beyond the seemingly more rational simplicity of choosing not to purge.  She told me, "I reach for the drum, and sometimes it's enough to keep me from sticking my finger down my throat THAT time."
There are a few final things I want to say.  First, it was the activity of drumming, the ritualistic nature of incorporating drumming into her life, and the unconditional acceptance and guidance given to her during shared drumming moments, that were therapeutic and targeted to her specific manifestations as an individual with anorexia.  This approach may or may not work for someone else with the same diagnosis.  Drumming did not cure her!!! The patient still actively struggles with anorexia and may for the balance of her life.  But we went deeper, higher and further into the realms of self-revelation and self-understanding because of the drum.  
Secondly, her spirit expanded.  Mine always does when I participate in a drum circle, but that's my story.  I objectively observed, as she enlarged the boundary of her social sphere and heart to reintegrate others into her life.  She wanted EVERYONE in a drum circle! Even as I write this, I smile at her enthusiasm.  We planned and had several circles where she brought people together who meant a lot to her along the way.  She would glowingly rave about how drumming was one of the "gifts, if you can call it that" of her disease.
Thirdly, I want to briefly comment on the difference between RECREATIONAL drumming and INTERVENTIONAL drumming.  Recreational drumming can and often IS an intervention! But let there be no mistake!  Interventional drumming is infinitely more than recreational alone.  Yes - it might BE fun; but no - it is not being used so the patient can have fun.  Interventional drumming is used just like any of a variety of tools healers and clinicians might use, such as medications, physical therapy, x-rays or crutches.   I have said in my facilitator-video on the Remo site that "I believe in the power and potential of the drum and HealthRHYTHMS to be an interventional program in the right hands of credentialed physicians, nurses, social workers, etc."  I certainly do!  But interventional programs require a level of expertise and health-related knowledge that allow the facilitator to use all they know in their specialty, along with all they've learned in the HealthRhythms training and protocol, in a patient's behalf. Someone without clinical credentials should NOT intervene in diagnostic milieu's and patient circumstances for which they are not credentialed, licensed or have interventional expertise.
Finally, what nourishes you?  This is a question worthy of an answer from both the sky of your mind and the cave of your heart.  Are you living life fully?  An anorexic patient had courage enough to tear down the facades of a life lived in secret and confront a disease that still torments her at each mealtime and every food-based, social gathering.  Drums and drumming help nourish her, as she plans her breakfast, lunch and dinner.  Can you pick up your drum and tear down your façade?  If you can, you're sure to be nourished!
Note: The opinions mentioned in this article are derived from the clinical perspective of the author, who has more than 25 years of experience as an advanced practice nurse, and counseling psychotherapist.  They are not intended for use outside the clinical setting with a licensed professional.



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