Now that I have her for a group again, I’m realizing that I definitely act differently with her as a facilitator — as opposed to the other group therapists.  It actually makes me nervous.  I can think of a few reasons for this:

1. She knows me well and calls my bluff.
2. Sometimes group topics are very similar to what we talk about in individual.  Maybe it’s just a coincidence, but I don’t know…
3. I don’t want to disappoint her and say something stupid.
4. I worry that her seeing me in a different environment will somehow lead her to change her opinion of me (and not for the better).

You would think that her presence would make me more comfortable (since we have a good relationship and I trust her), but that’s not the case at all.  I feel the need to perform — say something insightful, be a good group member, talk the right amount (not too much or too little), etc.  On some level I know that she’s not there to judge my group member-savviness, but I still feel this (internal) pressure to step it up a notch for her.  Make her proud?  I’m not sure.

Probably even more interesting is that I have similar feelings when the scenario is reversed.  On occasion, I’ve met with one of the group therapists on an individual basis (usually when my therapist is out of town).  I feel that same pressure to be a good patient.  However, whereas in the first situation I’m more worried about disappointing my therapist or leading her to think less of me, in this case I’m concerned about being worth the other therapist’s time.  I’m not her patient and she doesn’t have to see me, so she’s really doing me a favor.  I don’t want her to regret agreeing to see me in my regular therapist’s absence.

Now that I’ve written it out, this all probably stems back to my fear of disappointing people.  It’s also probably backwards that I’m so preoccupied with how the therapist is perceiving the time spent with me, instead of my using that time together to process stuff.

It’s just a matter of time until I test this theory… and not because I really want to, but because it’s inevitable that sooner or later I’ll say something really stupid in group (as if I haven’t already!).  Maybe it takes that experience of screwing up and not hurting the relationship to feel less fearful.  Or, maybe working with her in a group setting just takes some getting used to.

Sometimes I think that blankets should be banned in group therapy.  I understand that:

1. group rooms can be cold
2. body image is tough and it’s easier to hide behind a blanket
3. blankets are comfy
4. therapy can suck

… but really, how much are you getting out of group if your head is under the blanket?

I’ve been in an outpatient eating disorders group for awhile now.  There’s nothing special about it — it’s just a weekly / bi-weekly group at a treatment center, with women of all ages and ED diagnoses Everyone either has to be in outpatient therapy at the center or have done some kind of intense treatment there.   The latter is definitely the norm — most patients have stepped done from day treatment or IOP.

What’s weird right now is the make-up of the group: 5 restricting-anorexics and 2 binge eaters.  I don’t know where all the patients in between these two groups are.  I guess most of the women struggling with AN-R technically fall into the EDNOS-AN-R category, but you know what I mean.  There are no bulimics, and way more restricting anorexics than there should be–statistically.

There are three issues that I have with this:

1. There are too many anorexics in one room.
2. Since there really isn’t any middle-ground, the group feels very divided by diagnosis.
3. One of the girls is really really really underweight.  Really.

Issue #1: betta fish
I think that anorexics are like betta fish — you’re not supposed to put several of them in the same bowl.  I could expand this to all individuals with eating disorders, but I think that there is something especially competitive about anorexia.  Even when they are doing well in their recovery, putting too many of them in a group is just not a good idea.

Issue #2: no grey
I definitely believe that eating disorders are on a continuum and that we all have similar struggles despite the different diagnoses.  However… we seem to be missing all the people in the middle of that continuum.  It sucks to have BED and be in a group with all anorexics.  Heck, I think it’s triggering for anyone to be in that group (see issue #1).  With such a polarity, it feels a little them vs. us.

Issue #3: too sick
I don’t care how great you’re doing mentally — if you’re that underweight, you shouldn’t be in outpatient group.  You could be drinking boost like it’s water, and I still wouldn’t be okay with it.  It’s just too triggering.  I think it’s an especially bad combination in the current group, because the majority of girls have gone through refeeding in the last year and are struggling with body image now that they are at healthy weights.  Plus, personally, my whole “I don’t need to be here because I’m not that sick” complex starts creeping up on me.

Issues #2 and #3 are definitely elephants in the room.  Everyone feels weird about the divide and triggered by said sick patient.  No one will say anything (myself included).

I think you have to be so careful when putting together outpatient eating disorder groups… and I think that a certain level of physical health is necessary — even if someone is 100% gung-ho, yay-recovery-is-awesome.

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!

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…

“…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

I think that there are few “shoulds” in therapy (although I can think of a lot of should-nots!), but I am curious to know how long it takes others to settle in with a new therapist… I’m sure there are so many different variables (situation, diagnosis, type of therapist, previous treatment history, age, frequency of treatment, etc.), but how long does it take you to feel comfortable with a new T?

If I had to answer the question myself, my response would be, “Depends — how insightful is the therapist?”

If the therapist is going to wait for me to come out of my shell and tell her my story when I decide the time is right… it will probably never happen. Why bother? I need some indication of interest or insight or something. A couple of months back, my neurologist put two and two together (Wellbutrin + amenorrhea) and asked if I had any history of anorexia. And then if I had had an MRI because it could be hypothalamic amenorrhea. These questions of course lead to, “Well… ,” which leads to information that my therapist in college probably never even knew.

I’m not advocating a “don’t ask, don’t tell” policy… but it sure does help the “opening-up” process when you ask the right questions.

Technorati Tags: anorexia, bulimia, eating disorder, depression, treatment, therapist, eating disorder treatment, eating disorder recovery, mental health, mental illness, new therapist, ED therapist, recovery

I’ll have a grande CBT lite DBT Gestalt-free psychotherapy with two shots of psychoanalysis and breve IPT.

This image came to mind have after dinner with a friend last night. She’s been in therapy for several years, and has decided to switch to someone with “a little more of a CBT focus… who still integrates interpersonal therapy but spends less time talking about family.” Hmm… good luck with that search, Rach.

The reality of it is, there are so many types of therapy out there. Just to give you an idea of how many:

• Art therapy
• Cognitive-behavior therapy (CBT)
• Dialectical-behavior therapy (DBT)
• Exposure therapy
• Family therapy
• Gestalt therapy
• Group therapy
• Integrative psychotherapy
• Interpersonal therapy
• Hypno-therapy
• Marriage counseling
• Music therapy
• Narrative therapy
• Play therapy
• Psycho drama
• Psychoanalysis
• Psychodynamic psychotherapy
• Psychoeducation

… and on and on and on. Granted, some of these are much more common than others, and you could probably lump a lot of them together, but you see my point — what therapy is right for you?

No one therapy has been proven to be the best choice with eating disorders (especially anorexia), so your perception of recovery and ED etiology will be largely influenced by your first therapist. I think very few people have much information on all of the available types of treatment (not to mention the different kinds of therapists, psychiatrists, social workers, doctors, nutritionists, counselors, etc.). And even if they did… how do you know which therapy to try? And what exactly is the focus of therapy supposed to be? What is the interaction between you and your therapist supposed to be like? How are you supposed to feel when walking out of therapy?

There are so many beliefs in the psych field right now, that maybe you do need to customize your treatment like you would your Starbucks drink. And beyond that, maybe you’ll need to just around between types of treatment… not necessarily because you chose wrong in the first place (although that’s common), but because you have different needs at different times in your life and stages of your disorder.

Where this gets tricky, though, is with the concept of “bad therapy” — and if you’ve read my other posts, you’ll know that I believe that there is bad therapy. Maybe the kind of therapy that you gravitate towards is appealing is because it allows you to perpetuate your disorder or to ignore some issue. You can draw pictures forever in art therapy and never change any eating behaviors. Or, you can talk about your meal plan every single week with a nutritionist and never bring up a bad relationship that you’re in. So, I guess what I’m asking… is to what extent is therapy supposed to be comfortable? Is it no pain, no gain?

Any input would be appreciated…

Technorati Tags:
anorexia, bulimia, eating disorders, Starbucks, therapist, therapy, psychotherapy, interpersonal therapy, art therapy, cognitive behavioral therapy, dialectical behavioral therapy, eating disorders treatment, exposure therapy, eating disorder therapist, family therapy, gestalt therapy, group therapy, psychoanalysis, nutritionist, treatment, bad therapy