This time, I’ve been watching the series as intended — week by week, with all 5 patients in a row. It’s interesting how much the viewing order has changed my perception of the show. Originally, I saw things more from the patient’s point of view, rather than Paul’s (the therapist). I had no idea what was really going in in Paul’s life (especially since I didn’t watch the one patient, Alex, at all).

Now that I’ve been watching straight through the week, I see things more from Paul’s perspective. He has a life and various patients — all kids of things happen during the week. His real life affects his mood/actions in therapy (though he’s pretty good at separating the two).

It’s interesting to experience therapy from that perspective, since I’m always the patient. I know that my therapist has other patients – not to mention a life outside of the treatment center – but I’m not really thinking about that during our sessions. I’m only there one day a week, so I guess I expect things to be kind of where we left them the previous week. Granted, things happen in my life between sessions, but therapy stands still. Meanwhile, life at the treatment center moves on.

Another good example of this I’d with email. If I email my dietitian and she doesn’t reply, I get kind of frustrated. Sometimes I’m annoyed, but often I’m thinking “I shouldn’t have emailed her, it was a stupid question, she’s too busy” etc. I forget that it’s a one-to-many relationship. She’s my one dietitian, but I am one of her many patients. For all I know, she could get 100 emails a day. My one email is far more significant to me than it is to her.

Interestingly, this treatment point-of-view changes with level of care. When I was in a 5-day program, there was no time lapse between therapy. We were on the same page. I was THERE for all the other stuff. I was still just one patient, but was in a sense creating a lower patient-to-professional relationship (by occupying a greater percentage of time).

Anyway, the moral of the story is: watch “In Treatment” in order!

Tracking food:
I still track food exchanges (well, sometimes), and originally I could only find one app that was appropriate for this in the app store: EatRight.  After that I discovered Foobi, and most recently have converted to FoodTrackerPro.  Note: none of these apps use calories — just servings/exchanges — and I’ve been pretty pleased with all of them, but FoodTrackerPro is definitely the coolest.  PLUS, it works on the iPad, so bonus points for that.  You can customize your meal plan and make charts and set goals and all of that… but it also has a great food servings cheat-sheet — for all those times that you’re trying to remember how much hummus equals a protein exchange (for example).  iPhone/iPad, $1.99.

Tracking mood:
I started doing this on paper awhile ago and found that it was actually a good exercise for me (not only to see the patterns in mood but also just to check in with myself).  I’ve seen several apps for this, but currently my favorite is MyMoodTracker (same company as FoodTrackerPro, actually).  It’s only for iPhone (no iPad yet, bummer), but it tracks mood using a 1-10 scale and little emoticons.  You can track sleep on here, too, and see how that influences mood.  iPhone, $1.99.

Meds:
You know those times when you’re at the drug store trying to purchase something to help with your nasty cold, and you can’t remember if it’s okay to take Sudafed with the Wellbutrin you’re on?  That’s when you need Epocrates.  Or… when you have a headache and have already taken Tylenol twice and are not sure if it’s okay to take another dose yet?  Okay, maybe it’s just me, but I run into situations like this all the time and would be lost without this app! Plus, when you’re on more than one med at a time (which is pretty common these days), things get complicated (drug interactions, dosing, side effects, etc), and it’s just good to have it for reference.  iPhone, free.

Countdown:
By now you’re probably thinking, “okay, you track way too many things”–and it’s probably true.  BUT, do you know what’s even better than personally tracking something?  An app that does it for you!  That’s Countdown.  I have countdowns for everything — how long I’ve been married, how long it’s been since I last acted on symptoms, how many days until my next therapy appointment, how long until my birthday (hey, why not….), etc.  Random countdowns aside, there’s something really motivating for me about knowing that I haven’t skipped a meal in three months, or drank coffee since…. err, yesterday (okay, really bad example), or that I have therapy in 1 hour, 42 minutes and 18 seconds (and really need to do my therapy homework).  I just love seeing that.

Coping Skills:
Remember my series on coping skills?   Well, for each of those items, there is of course an app for that:

1. card stores – it’s not a card store, but someecards can entertain me for an embarrassingly long period of time (both the app and the website).
2. bulletin boards – Corkulous would probably by my favorite app-equivalent of a regular cork bulletin board.  However, the real purpose of bulletin boards for me are to serve as reminders, so that the “out of sight, out of mind” thing doesn’t kick in.  For that, I’d probably actually use a todo app or custom background/wallpaper (not going to link these because there are a million and I don’t have a favorite!)
3. kudos chart – again, this is something you could probably find in a todo app, but if you’re looking for something a little more…. sticker-chartish… try GoalTracker (ipad).
4. crafting — there are a million apps for: coloring, collaging, drawing, photo-editing… really, a million. You might start looking in Apps for Kids.
5. dvds — you can download just about anything from tv/dvd onto your iPhone/iPad from the app store.  Additionally, ABC has an awesome media player that lets you stream shows for free.

Okay, that’s the end of my list for today.  If anyone has any other app suggestions, I would love to hear them!

Your problem is you’re… too busy holding onto your unworthiness. – Ram Dass

As someone who’s struggled with an eating disorder for longer than I would like to admit, I’ve definitely had periods of falling into the “I suck at recovery” trap.  It connects directly to the “I am wasting everyone’s time and don’t deserve help” trap as well as the “I’m actually fine and asking for too much because I’m attention-seeking like that” trap.  And let’s not forget the “It’s not fair that my family / friends / husband / dog have to deal with my having an eating disorder” trap.  I have a complex and well-developed network of traps, apparently.  Kind of like dig dug.

What happens is that I get SO CONCERNED that I’m asking for too much help or am burdening everyone so much that I don’t actually make any progress in treatment.  Because, what if I’m crying wolf and don’t actually have an eating disorder?  Then making progress in therapy is irrelevant because it’s not like there’s anything to treat in the first place.

My problem during these periods is exactly as the quote describes:  my preoccupation with my unworthiness for help keeps me stuck.  I need to stop obsessing over whether or not I’m too needy and just get it through my head that I still need therapy.  THEN we can actually do something therapeutic.  Nothing productive comes from holding on that “I don’t deserve help” idea.  Doing worse or not telling my therapist anything for fear of “burdening her” probably just causes more frustration for everyone.

I know I’m not the only one who struggles with this, because I see it all the time with friends.  I’m sure it’s something worth exploring in therapy — why do you feel unworthy?  However, I also think it’s the result of a lot of arbitrary expectations and “shoulds” — that there’s a maximum length of time you should be in treatment, or fixed amount of help that you should need.  Using that logic, when you exceed those two years of therapy (I’m completely making that number up), it means you’ve worn out your welcome in the treatment world.

The other idea that I get from this quote is the security of holding onto the “I’m not good enough” idea.  My therapist would tell me that I hold onto the unworthiness thing because it’s easier to make myself the “bad” one than to admit that people around me couldn’t/didn’t meet my needs… and maybe that by continuing to hold onto the idea, I’m protecting myself from being let-down again.  I don’t know about all of that, but I do know that being in the “I not worthy / deserving / needing of” trap does definitely keep you stuck.

Note (05/02/2010): I’ve updated the mind-map to a) remove the typo and b) make it bigger for printing purposes.  Click on the image to load the larger diagram.

It has occurred to me lately how often I say “I don’t know” in my appointments (possibly even more often than I say “I know” !).  My therapist has come to totally disregard the phrase, which for me, has become very versatile:

Type 1: the how-did-you-feel-in-that-situation “I don’t know”
Usually used when discussing some childhood event that I kind of remember.  I could probably figure out how I felt about it, if I spent some time thinking about it, but I really don’t want to… so off the top of my head I don’t know.

Type 2: the I-do-know-but-I-don’t-want-to-tell-you “I don’t know”
There are lots of reasons why I might know and not want to say anything….

1. I don’t want to analyze it, and I know that my therapist is going to
2. I’m embarrassed
3. I don’t have the energy to get into it at that moment
4. I just don’t feel like telling her

Type 3: the can-this-conversation-end-already “I don’t know”
This “I don’t know” is often accompanied with a lot of “uh huh”s, “yeah”s, and “mmhmm”s.  Saying anything besides “I don’t know” is going to continue the conversation, which I definitely do NOT want to encourage.

Type 4: the I-don’t-believe-you “I don’t know”
Usually a response to a statement rather than a question… when I’m being told that taking care of myself is important and it’s okay to ask for help and I’m not too needy, and all of those other things I have a hard time believing.

Type 5: the I-want-you-to-tell-me “I don’t know”
Okay, sometimes I test my therapist, and sometimes I just want to be told things.  I know what I think, I’m bored with my answer, and I want a professional’s perspective.

…you know, the more I think about this, the more types I can come up with.  Maybe I should just make a mind-map:

I can definitely relate to this. When you first start a higher level of care (like IOP, PHP, IP – anything involving a meal), the amount of food you have to eat (and keep down) is a little overwhelming. At the same time, there’s a little bit of relief that comes with eating at program. You don’t have to make the decision of what to eat yourself. You really don’t even have to take any responsiblity for eating. The meal is structured, dietitian-approved, and you could spend the next couple of hours processing the horror of the meal if necessary (although hopefully not).

While thinking about this, I decided that there are four stages of eating in treatment (in this sense):

1. Eating at program is really hard. It’s more food than you would eat on your own (or not purge). You’re struggling with acting on symptoms at home, and meals at program are much more “normal” and overwhelming than you’re used to.
2. Eating at program is still hard — but for a different reason. You are actually starting to eat more normally at home, and it really feels like too much when combined with all the food at program. You feel guilty for not compensating (or not purging).
3. Eating at program is easier. This is because
             a) you’re used to the meals by now
             b) you’re taking food risks at home (eating fear foods, going out to eat with friends, challenging food rituals, etc.)
   The food at program feels reliable and safe in comparison.
4. Eating at program is boring — and even annoying. You’ve eaten a veggie burger every week for two months and feel that you could go the rest of the year without eating yet another yogurt. You would rather be eating at home — not because you want to restrict, binge, or purge, but because you want to eat something better (that you actually like) or be eating with other people.

I could probably come up with more stages, but these four are the most obvious to me. I’d love to hear your thoughts…

1. Feeling your feelings – good, bad, and everything in between
2. Your body adjusts to where it needs / wants to be (based on your own genetics)

Johanna supports these two ideas with a lot of great thoughts, so I definitely recommend that you read the post.  However, what really caught my eye was one of the comments:

My therapist told me yesterday that “people try to get out of their eating disorder by going into their eating disorder.” I slipped a little in the past two days. My therapist said, “You’re in the hole, but you’re trying to get out of the hole by going farther in the hole. You don’t climb out of a hole by going down. It’s like people are hoping so hard that if they just go farther into the hole, they’ll find a secret back door that will let them out more easily. The truth is, there is no back door. It’s a cul-de-sac. It’s painful to be in the hole, and it’s painful to come out of the hole. But there is only one way out. Up.”

Laura so eloquently articulated something that’s going to take me five paragraphs to describe.  Everyone has heard the phrase about things having to get worse before getting better.  However, it doesn’t say MAKE things worse so that they can get better.  It doesn’t exactly work like that.  I see a couple of different situations where people “try to get out of the eating disorder by going [further] into their eating disorder”:

1. Trying to replace one symptom with another
2. Not feeling “sick enough” to recover
3. Waiting to hit rock bottom
4. Trying to do recovery perfectly

To explain a little further…

Trying to replace one symptom with another
Replacing bingeing or purging with restricting is not recovery.  Replacing restricting with compulsive exercise is not recovery.  It’s tempting to say, “okay, I’m going to stop bingeing and eat only healthy food and lose weight.”  I think this just exacerbates the binge > purge > restrict cycle.  It seems unintuitive… but I think part of the recovery process is learning to forgive yourself when you do screw up.  It’s being a little more lenient with yourself… not stricter.

Not feeling “sick enough” to recover
I’ve blogged about this several times.  There’s the whole “if I were really sick, then I would recover” idea.  Or “if I just lose 5 lb., then I’ll feel ’sick enough’ and will feel justified in trying to eat more and get better.”  There is no “sick enough,” though.  Digging a deeper hole is not the answer to getting out!

Waiting to hit rock bottom
This is the “I’m still functioning, it’s not THAT bad” rationalization.  Or the “I’ve been worse before” idea.  There doesn’t have to be a rock bottom.  While true that some people have that moment when something really awful happens and makes them realize they are ruining their lives and have to change, I’d say those individuals are more the exception than the rule.  I’ve had “rock bottoms” (note the plurality), and sure, they motivated me to change.  However, the times that I really committed myself to recovery were not near those bottoms!  I’m very guilty of the “I’m a functioning person so I’m fine” excuse.  I have to stop and remind myself, “Why would I want to wait until I lose my job, ruin relationships, have a heart attack, etc.?  Can’t I just avoid that horrible bottom and work on getting better now?”

Trying to do recovery perfectly
I know so many people who want to keep “restarting recovery” so that they can “do it right this time.”  Restating seems to imply getting worse… so that you’re back at the starting line to try again.  I’ve done this over and over with eating and my fear of having a slow metabolism forever.  If I’m not following my meal plan, yet maintaining my weight, I am convinced that I screwed up in the recovery process somewhere and am condemned to a life of having to watch my weight because I’ll obviously gain eating a normal amount of calories.  And then, what’s the solution?  To lose weight, of course… so that I can try that again and follow my meal plan and trust the science of it all.  When you’re deep in the eating disorder, it seems to make a lot of sense.  But, looking at it from the outside… why would I think that doing worse would be the solution to getting better?

Laura summed this up so well: You don’t climb out of a hole by going down.

“…Hans Christian Andersen’s The Emperor’s New Clothes, a tale about con men who promise an emperor a new suit of clothes invisible to those unfit for their positions. When the emperor parades naked before his subjects, a child cries out, “The king has nothing on!”

Judith identifies with the emperor who allows himself to be duped because of his own self-delusions. Therapy, she says, deceived her into thinking she was in more in control of what was happening to her than she was and that “through reason, determination and an outlay of cash” she would be able to overcome a lifelong depression.”

I never thought of relating therapy to The Emperor’s New Clothes, but it’s a a really clever allusion.  I think it sums up one of my fears in trusting a therapist.  Maybe I’ll call it the Emperor’s New Clothes Phenomenon.  Hmm.  Anyway, I think this can be a big misconception.. that through the magic of talking about your childhood, therapy can cure all of your ills.  You show up, talk a lot, get some sage advise from your therapist, and bam!  Mental illness cured.

She is understandably angry, more with herself than with her Freudian clinicians: all those years wasted in misery, the attention she didn’t give the people she loved. Her self-preoccupation and childhood focus had put a great deal of tension on her relationship with her parents and distanced her from her husband and son.

I’ve never done true psychoanalysis, but have had therapists who leaned in the direction of psychodynamics.  I won’t lie and say I don’t think there’s any use in talking about past stuff – because in a lot of scenarios there is.  However, there have been times when I explored my childhood and all the possible problems that went along with it, and still didn’t really feel better (nor was my eating disorder better).  My therapist would tell me how much progress I was making and how I was having these great breakthroughs, and I decided I’d just have to trust her, because I really wasn’t sure what she was talking about.  At some point I just got angry, because I felt that there was so much going on in my life NOW that was significant.  Plus, I was spending so much time reading old journals and thinking about things that happened fifteen years ago.  I was not very present in my own life.

Judith articulates this beautifully in one line:

“With my mind free of the minutiae of self-analysis I can tune into what’s around me in new ways”

Anyway, I think that some individuals believe that there are two types of people in this world: Those who’ve had therapy and those who have not.  The people who have processed their unconscious thoughts and all of the significant events in their life have some kind of self-enlightenment.  Those who haven’t are walking around in the dark.

The next time my therapist asks me “How do you know when you are done with treatment?,” I am definitely going to answer “When I can see the invisible clothes.” (Though, that comment might actually land me in several more months of therapy…)

Picture Credit: Annie White at Studio Whites

This said… something that has always thrown me off is having my individual therapist as my group therapist.  This has happened to me a couple of times, in residential, IOP, outpatient, etc.  It changes the dynamic for me for a couple of reasons:

1. Every time I said something to the group I though, “has she heard this already?  did I tell her this before?”
2. I read (too much) into the things that she said
3. If I were having a bad day, she usually noticed
4. I wondered if there would be repercussions to the things I said (for example, I didn’t want to mention something in passing and have to spend the next two individual sessions processing it).
5. I worried that I’d treat group like an individual session and spend too much of the total time focusing on my own issues

These aren’t all bad things.  It’s good that my therapist would recognize that I was having a crappy day, since I likely wouldn’t have brought it up and the therapists who didn’t know me as well probably didn’t know anything was not right.  She also probably pushed me a little harder, since we did have a relationship and she could do that comfortably.  So, for the most part, it was good for me to have some groups with my individual therapists.

With all of this said, where things start to get a little messier is when other people in the group also share the same individual therapist.  I’ve been in some programs where everyone had the same primary therapist and others where there were a handful of individual therapists that also ran groups.  Both situations add that extra variable to the equation – sharing a therapist with another person in your group.

The therapeutic relationship is so unique that sometimes I think it can be challenging to “share” your therapist with someone else that you know.  I’m not concerned about the confidentiality as much as the dynamics of the relationship.  As the patient, you only have one therapist.  When you have a good relationship, it feels special.  You feel like you have this connection that maybe other patients don’t have.  It makes sense – every week you are confiding in this person, trusting him/her to guide you and to give you some insight.  This relationship and person mean something to you.  He/she is a part of your life.

Being in a group with your therapist and another one of her patients is a reminder that you’re not the only patient.  You know this logically, but the reminder can be kinda tough.  Sometimes it’s rough to see her concerned and focusing on someone else.  It can feel invalidating.  It can feel like a competition between you and the other patient.  It can be hurtful if you feel like you’re being ignored or that your interaction with the therapist is different.  It really adds a dozen additional variables into the therapeutic relationship equation.

There are a lot of things that make eating disorder groups tough.  Girls get competitive over eating, weight, exercise, etc – even if you don’t allow talk about numbers.  You have to be careful who you put in a group together, and even having one or two pretty anti-recovery people can change the whole atmosphere.   Sharing a therapist with several of the girls almost adds another thing to compete over.  Even if you refuse to participate in the competition to get the most attention or require the most concern (really, these competitions exist!), it can be hurtful to to feel neglected or uncared about.  I don’t think this is a topic that is often addressed in groups… but I think that sharing a therapist with other girls, and all being in the same group together led by your primary therapist, can be a little tricky…

You as your own case manager
Originally Posted: 01/01/2009

I wish that all these guys were going to stay clean, I really do. I’ve just seen it so many times that I can tell when someone’s really willing to do whatever it takes and when someone’s willing to do what they think it should take. And it’s just not going to work like that, unfortunately.

–Shelly, Celebrity Rehab with Dr. Drew 2

Wanting to want to recover
Originally Posted: 06/12/2008

Motivation to change implies an intention–weak or strong–to change one’s behavior. However, AN patients may at the same time both wish to recover and be highly resistant to change their behavior. Therefore, we suggest that assessment of motivation in these patients should include not only their motivation to change, but also their different wishes to recover which do not necessarily imply a behavioral intention.

Dr. Drew should treat eating disorders
Originally Posted: 07/01/2008

There are a lot of components of addiction treatment that I believe in and think are important, and should be applied to eating disorders:

1. Recovery is a lifelong, daily process
2. Denial, and not necessarily that you have a problem, but that you need help
3. The importance of personal accountability
4. There’s no magic cure
5. The disorder should be taken as seriously as any potential fatal disease

Do not pass Go, Do not collect $200
Originally Posted: 12/09/2008

“I don’t want to play the rehab game anymore”

– Jeff Conaway, Celebrity Rehab 2

I think that recovery can feel like a game at first because it is so different from the rest of your life. It’s nice to have others care about your wellbeing and there’s something about treatment that gives you permission to take care of yourself. Plus, there is so much positive reinforcement (gold star for following your meal plan over the weekend!). All of this doesn’t sound so bad… and I do believe you can make progress — even with this mindset.

When does the game end? Personally, I think this is when the disorder starts to feel threatened. There is something scary about recovering, and suddenly it doesn’t sound like a great idea anymore.

“I’m not deflecting because I’m avoiding something deep. I’m deflecting because I’m avoiding something shallow.” – House, MD

One of my biggest treatment pet peeves is when professionals ask non-deep “deep” questions. For example:

1. What does it mean to feel?
2. How did it feel to be in that space?
3. How does it feel to be in this space now?
4. What does it mean for you to not be in that space anymore?
5. How do you experience that process?
6. What would it mean for there to be grey in your world?
7. How does it feel to have acknowledged that out loud?

Okay, depending on the situation, some of these questions could potentially be useful. However, I’ve had therapists who use them over and over and over again. “What does it mean to feel?” is probably my least favorite question of all. Maybe it SOUNDS deep and therapeutic, but there are really only two answers to this question:

1. It means that I have feelings
2. It means that I am allowed to have emotions and that it’s okay for me to recognize them and not judge them as being either “good” or “bad”but to just accept them as they are… and that emotions may be scary but I can work through them and get support to handle them… and that they are normal and a necessary part of human life and essential to enabling us to connect to other humans and form relationships….

My point is, your answer is either “this is a stupid question” or “I just had this revelation about the significance of feelings and everything else in my life.” And if your answer is the first, then it’s “But what else? What does it really mean?” This is where the House quote comes in. I’m not deflecting the question because I don’t want to address some deep underlying issue, but because it’s really not a deep question! And if you won’t accept “Um, it means that I have feelings” as an answer, then you are going to get whatever fictitious BS I can come up with off the top of my head. Plus, I’ll be frustrated and won’t want to intelligently answer your additional questions.

You can ask me what I’m feeling, what I felt at that time, how I feel about feeling that way, etc…. but I hate when it is reworded to sound like a deep question. “How does it feel to be in this space now?” is just “How do you feel?” with six extraneous words.

Wow, I swear I am not as bitter (or as difficult of a patient) as I sound in this post! I just don’t like shallow questions that are pretending to be deep.