Therese refers to the tips/tricks she picked up in therapy as “emotional CliffsNotes.” Ever since reading the book, I’ve thought about what I would put in my own emotional CliffsNotes. I have a friend who would probably say I’m just looking for an excuse to make yet another list — which may be partially true — but hey, if I can make a blog post out of it too….

Anyway, a couple of months ago I ran across an awesome article over at Stepcase Lifehack, called “Can You Transform Without Getting Uncomfortable?” Craig’s main point was this:

Hypothesis: There is a positive correlation between how uncomfortable an individual is prepared to get and their likelihood of success – irrespective of the field of endeavor.

This idea reminds me of something my therapist told me once: that anxiety is a good thing. I thought she was nuts (or just wrong) at the time, since I was devoting so much time to controlling/minimizing anxiety. She explained though, that when you’re feeling anxiety, that’s when you’re making progress. The mental anguish that comes with facing uncomfortable things (like eating more, weight gain, handling conflict, being assertive, etc) is a good thing.  It means you’re making change… and that’s what you have to work through.

It was really weird for me to look at anxiety as some positive indicator of change rather than some big red “stop! uncomfortableness ahead!” sign. What I got out of the conversation at the time was that if I were waiting for recovery to be comfortable, it was never going to happen. Challenging the eating disorder was never going to feel good (at least not while still in the thick of it).

Reading Craig’s article put a different spin on it for me, though. I was still looking at anxiety as something inevitable that I had to push through to get to the other side. The blog post opened me up to the idea that uncomfortable does not equal bad. It’s just uncomfortable.

By the way, I’ve been meaning to write this post for a month (at least), but was re-inspired by something that I read on Carrie Arnold’s blog today:

The main factor for me was anxiety and fear about changing my behaviors. I was often tired of the eating disorder but unable to push through the anxiety that was keeping my ritualistic behaviors in place. Thus the status quo remained in place. My other issue was that this fear was coupled by my minimizing the issues that my AN behaviors created. They weren’t that bad, I could handle it, most people were on a diet- how was my life different? So how could I be motivated to work on a problem that I often wasn’t even sure I had?

I know that anxiety! It keeps me stuck, especially when it comes to the eating disorder.

While I’m not in a position where I have to calculate hours spent on a task, I was thinking about how the eating disorder would affect my focus factor.  It’s kind of scary (and pathetic) when you really think about how much of your time the eating disorder can consume.  Obsessing about your weight, what you’re going to eat, what you already ate (etc) is really distracting.

I tried to break down the components of my focus factor, and came up with the following pie chart:

Eating disorder-wise, this isn’t really current for me.  I’d say the numbers are accurate for when I’m struggling moderately — not at my best or my worst.  When you add it all up, I’m really only focused on work for 1/3rd of the time I should be working (this isn’t including the rest of the non-work day).

One time when I was struggling, I cut back my work hours to do day treatment.  I fussed about what a disaster it was going to be to not be getting work done.  I was afraid I’d be letting my coworkers done and hurting the overall quality of my team’s work.  As it turned out though, by getting more treatment I drastically reduced the amount of time I spent on all those ED thoughts and ended up being MORE productive.  Go figure.

My therapist still loves to bring it up, in some kind of “remember how you are actually more productive and successful when you make treatment a priority?” comment.  While it’s definitely true, I knew I shouldn’t have admitted it…

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.

“Addiction is the only disease that you have to convince people that they have.”

I highly disagree with this statement, and think that denial is a large part of many mental illnesses… and even some physical illnesses. Just to name a few:

• eating disorders
• personality disorders
• depression
• ptsd
• dementia

Sometimes people just don’t want to admit that they’re struggling with a mental illness (maybe they think it means they’re a weak or defective person). Sometimes people feel their issues aren’t severe enough to warrant a diagnosis. “I’m not depressed — I’m just in a negative funk.” Some of this probably has to do with the stigma and stereotypes of people with these diagnoses. You always think of the most severe cases. With anorexia, you think of an adolescent girl who’s emaciated and never eats, ever. With depression, you think people who never leave their house and cry all the time or are suicidal. With PTSD, you think rape or child abuse or something horrific. You end up comparing your symptoms with those on the far end of the disordered spectrum… and then of course you feel like you’re okay! There’s also the misperception that you can’t be sick and be functional in life. You can be both awesome at your job and still very disordered.

Denial and minimization are hallmarks of eating disorders. There are probably a thousand different reasons why, but to name a few:

• not feeling “sick enough”
• still functioning in everyday life — maybe you’re even very successful in other aspects of life
• weight is not extremely low (maybe it’s even normal or above)
• still eating (or keeping food down) sometimes
• you have previously been much sicker & are comparing current symptoms to those during the height of your disorder
• “everyone has somewhat disordered eating”
• “I am healthy enough”
• all-or-nothing thinking — you have one or two good days and feel that you are therefore fine
• fear of having to change

One difference between addiction and eating disorders, is that you are forever a recovering addict (at least that’s the most popular ideology). You can be sober for 40 years, and you’re still a recovering alcoholic. With eating disorders, you can jump all over the diagnostic landscape. There’s switching between disorders, periods of recovery, relapse, and maybe full & sustained recovery. Because of this, you may have to be convinced a dozen times in your life that you have an ED. And, with the line between normal and disordered eating being so fuzzy (diet food… disordered or not?), it can be hard to tell whether or not you have an issue.

Convincing someone that they have an eating disorder can be a long, frustrating, and repetitive process. I’m very biased, but I’d even venture to say that EDs take more convincing than addictions.

This evening I was reading Carrie’s post on overcoming core traits.  Personally, her post was very timely, having just finished reading the book, “When Perfect Isn’t Good Enough.”  That is NOT a book that I would normally pick up (I feel pretty well-versed in perfectionism), but my therapist handed it to me.  In hindsight, maybe I could have NOT read it and argued that I was challenging my perfectionism by not doing my therapy homework.  Oh well, next time…

Anyway, the book made a lot of good points, and I could write a dozen posts on it (maybe I will… another day), but one thing that really stuck out for me was the idea that perfectionistic behavior maintains perfectionistic beliefs.  I understand the whole idea of challenging perfectionistic beliefs and testing their validity – that wasn’t really a new concept for me.  What I am curious about, though, is if perfectionistic behavior can exacerbate perfectionistic beliefs, and therefore anxiety?

A year ago, I switched jobs to something that required a lot of persistence and focus to detail.  A LOT.  How perfect – I can get paid for my OCD-like tendencies!  When the job opportunity arose, I really approached the career change from a square block, round hole perspective.  Instead of trying to be less perfectionistic, I could just switch to a job that encouraged it.

After reading this book, I’ve started to wonder if my meticulous work makes my anxiety worse.  I can (and sometimes do) agonize over details all day.  I’m always engaging in perfectionistic behaviors.  Is that impacting my beliefs?  And do those beliefs influence other areas of my life?  Instead of work being an outlet for the OCDness, is it just making those tendencies worse?

I like my job and am not about to change that, but it’s an interesting thought.  Does perfectionism breed more perfectionism?  Even accross life domains?  Hmm.

“Currently, we are concerned about young people using the Internet, eating too much, spending irresponsibly, and being promiscuous, and these worries are being expressed in the language of addiction. The medical terminology helps us to believe we’re avoiding moralization or blame, and popular science has given us a sound bite of pseudo-neurology to support our prejudices. For these problems, addiction is little more than a fig leaf for a realistic understanding that would address why people return to unhelpful ways of coping with isolation, stress, and depression. Instead, we prefer to rely on a trite and unhelpful catch-all label that prevents people from getting appropriate help for their difficulties. We need to break the addiction habit, before it breaks us.”

–Slate, The Addiction Habit

My first thought when reading this article was “ouch.” I’m not an addict, but still, that’s a pretty strong statement. Addiction as a fig leaf. Hmm…

I’ve written a post on this before (A diagnosis for everyone), which would largely agree with the author of the mentioned quote. I do think that the addition label is used too literally.

However… after having watched Sex Rehab, I have a slightly different view on the subject. In terms of true addiction, I’ve always really only considered drugs and alcohol as qualifiers. I wouldn’t even say an eating disorder is an addiction (although many would argue with me), just because there isn’t one identifiable thing that you are addicted to. There are a lot of similarities between the two, though. Anyway, that’s a debate for another day.

Regardless of whether sex addiction is a “real” addiction, these people came and got help. There was much more that they needed to deal with than just the sex – most of them had either some kind of abuse history, unresolved issues that were affecting their daily lives, or an underlying drug/alcohol issue. Whether or not sex addiction “counts,” these people were really struggling with a lot of stuff in life. They definitely left in a better place than they started, and I’m sure that the ongoing treatment can help them be healthier, happier people with satisfying relationships (hopefully).

They wouldn’t have made these changes unless they were removed from their everyday lives. They needed a rehab. They wouldn’t have gone to rehab unless they had a real problem, though. If sex addiction didn’t “count” as real, who knows if they would have ever gotten help.

So I guess my point is… yeah, the word addiction is definition used too liberally. Internet addiciton and sex addiction are most likely in a different category from substance addiction. However, I disagree with this part of the quote:

“…we prefer to rely on a trite and unhelpful catch-all label that prevents people from getting appropriate help for their difficulties.”

I think that MORE people get help when their struggles are verified as real problems. If you spent your entire adult life playing online role-playing games, to the detriment of your career and relationships, then yeah, I’d say that’s a problem? An addiction? ehhh… I don’t know. But if labeling it as such would give someone the permission to get help for something they can’t get over on their own (isn’t that largely what it comes down to? getting help for a problem that you can’t handle by yourself? that’s hurting you, your loved ones, and your life?”), then sure, call it that.

Maybe we shouldn’t call these behavioral obsessions “addictions” – but we should come up for something that validates them. The article makes a relevant point:

“Recent work by psychologist Meredith Young and colleagues at McMaster University in Canada has shown that if we replace a common name for an illness with a medical term—pharyngitis for sore throat, e.g.—people tend to perceive the illness as being more serious.”

Okay, so come up with some scientificish name! Someone must know what “behavioral obsession” is in Latin. Just give it a real name so people can recognize it as a real problem.

There are lots of situations where I’m tempted to say “use your words!” (don’t worry, I usually resist the urge).  Often this is with the ED, becuase often people use their eating disorders to communicate.  I’m a huge offender.

For me, restricting could mean…

• I’m not okay
• I need more help
• I am overwhelmed and can’t handle life
• I need a reason to be cared about
• I feel undeserving
• I want someone to think I matter
• I’m having a bad day
• I’m anxious
• I’m depressed
• I’m lonely
• I’m frustrated
• I’m hurt

There are so many things that I won’t say (and things that I won’t even let myself THINK).  Somehow, though, saying them through the eating disorder makes them valid.  Maybe it’s because there is physical proof that something is not right.  Regardless of how I feel (because really, who cares about feelings?), I’m hurting myself and that you can’t ignore.  That matters.

The problem is, this is a really ineffective means of communication!  Restricting could mean a hundred things.  Throw bingeing, purging, SI, exercise, laxatives, etc. into the mix and you have enough symptoms to illustrate your whole emotional vocabulary.

However, it might as well be your own secret language, because no one else really knows what you are trying to communicate.  You’d probably be better off investing in some flares and arranging them to say “HELP” in your backyard.  Or learning morse code.  Or writing down “I’m not okay” and sending it to someone that you care via carrier pidgeon.  Why?  Because you could be overwhelmed and acting on symptoms at every available opportunity to deal with the stress.  Eventually something will happen – someone will notice, you’ll end up in the ER, you won’t be able to take it and will quit, etc.  Something WILL happen.  However, it’s likely not a happy ending.  Do you know how much more effective it is to just SAY something?  Say “I’m feeling overwhelmed.”  If it’s at your job, then you can figure something out to make your work load more manageable.  If it’s with life in general, you can figure out how to get more support, prioritize things, delegate more, weed out less important responsibilities, etc.  You just need to SAY something.

Granted, it’s really hard to do this (for myself as well).  I think some of the reluctance to talk is related to fear – fear of others knowing you’re not okay, fear of ruining relationships, fear of asking for too much, fear or others caring… lots of fears.

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…

1. It’s called Loveline
2. Half of it is sex talk
3. I have to pay $5 a month for it!

Still… It’s Dr. Drew, so I have to do it.  There are calls about addictions and psychological issues, and listening to his responses to those questions is worth my $5.

Dr. Drew had a particularly great quote today:

“It’s not what you’re doing, it’s what you’re missing – and you deserve better.”

The quote was not in relation to alcoholism or eating disorders, but it really hit home with me.  Yes, you need to get better because it’s important to take care of yourself, people care about you, you should care about you, you want to be healthy, it’s pathological, etc.  But also, when you are wrapped up in the ED you are missing life.  Maybe that’s semi-intentional; maybe you’re avoiding life.  You might think you’re just coping with life in an unhealthy manner, but you really are missing it.

You’re missing:

1. Close relationships with friends
2. Many normal social situations (getting pizza, going out for lunch, meeting for a drink, getting ice cream for no reason)
3. Good experiences (as well as bad experiences) that shape you as a person

I can think of a lot of things that I “missed”

1. Close relationships with HS friends
2. Trying anything new (for most of my life)
3. Getting ice cream with friends
4. A lot of summer cookouts
5. Trips I wouldn’t go on because there would be too much food or b/c I was depressed & wanted to stay home
   (okay, this is a depressing list so I’m going to stop here)

I think that eating disorders are as much about avoiding life as they are hurting yourself.  First there is all the time that you spend wrapped up in the disorder.  You’re isolating, avoiding events with food, and spending 90% of your day thinking about food and weight.  You have no idea what is going on around you.  And then there’s treatment, which takes up even MORE time… because along with the continuing disordered behavior (it’s not going to go away overnight), you now also have a dietitian, a therapist, a doctor, a psychiatrist (and this is assuming that you don’t really put your life on pause to go to a residential or partial hospitalization program).  You are spending your free time in treatment.  And I don’t know about you, but when I’m working on tough stuff in therapy, I have a harder time dealing with the rest of life.  When I’m upset about whatever my therapist said two hours ago, the last thing I want to deal with is a presentation that’s due tomorrow.  So yes, even in recovery, you are avoiding / escaping / missing (whatever you want to call it) your life.

It’s kind of ironic when you think about it.  You spend so much time in therapy trying to change behaviors, discussing why you are coping with life via your ED, identifying unhealthy aspects of your career and relationships, etc.  However… how much time do you spend talking about what you’re missing?

And for awhile, this is the point.  Maybe something in your life is not okay.  Maybe there is too much on your plate, maybe you are in a bad relationship, maybe you do need to change your job, maybe you are killing yourself trying to please everyone else in your life–whatever.  One of the best things about residential (I think) is that you don’t have to deal with the real world while you’re in treatment.  I can just focus on myself and what I need to be doing without the constant stress and anxiety of bills, relationships, responsibilities, work, money, and the list goes on.

However, I am not new to treatment, and neither are several of my friends.  And while I do worry about their health and their symptoms, what really makes me sad is what the ED takes away from them.  For one friend, it takes away time and energy that she would rather be spending with her children.  For another, it limits her career because work has to be planned around the ED and ED treatment.  Another friend has to put relationships, summer plans, and a lot of the life that she has created in the past year on the side right now to get more intense help.

All of these friends are making the right choices to work on the eating disorder and to get the help that they need!  Absolutely.  Friend #1 can’t take care of her family if she isn’t taking care of herself, Friend #2 won’t be able to put the energy and concentration into the job that career that she really wants until she is healthier, and Friend #3 won’t be able to maintain that life if she doesn’t do intensive treatment.  My point is, though, that what saddens me the most about these friends is not their concerning ED symptoms, but all the things that they are missing out on in their lives.  They’re such wonderful people and are meant to do so much more in the world than they can with this eating disorder.  They deserve so much more out of life than this eating disorder, and that’s why I hope they can get better.

To summarize:

Because her health is directly related to her weight.  Measured by scales.
Her recovery is directly related to her weight.  Measured by scales.
Her life is directly related to her weight.  Measured by scales.
Weight matters.
And scales matter because they measure weight.

I posted a comment on this post, which hasn’t been approved yet, but I decided that I wanted to discuss the issue on Grey Thinking anyway.

Yes, weight is inexorably tied to health and to recovery.  Weight restoration is vitally important to recovery.  You can’t be recovered and still be below the healthy weight range.  Professionals need to monitor weight.  Some treatment decisions need to be made based on weight.  In short, I am not at all arguing that weight is unimpotant for recovery.

With all of that said… I find a lot of diagnostic criteria and treatment approaches to be contradicting and frustrating.  In therapy, you’re told that you are not a number.  That you are lovable regardless of what the number on the scale says.  That coping with food / weight is not okay.  That eating should be mindful and emotional eating is unhealthy.  You don’t have to be sick to deserve care.

But think — how is your health measured?

• weight, BMI, % of IBW
• calories, exchanges, % of meal plan completed
• heart rate, blood pressure, potassium, electrolytes
• # of binges / purges, # of laxatives, # of diet pills
• hours exercised

… see my point?  Everything is measured in numbers.

I have an issue with your mental health being measured in numbers.  From this point of view, gaining weight = a good week and losing weight = a bad week.  That has just never been a linear relationship for me.  I have bad weeks and gain weight, and vice versa.  Sometimes I follow my meal plan and lose weight, and other times I restrict and gain weight.  The system reinforces the necessity of communicating through your eating disorder.  If you’re feeling crappy but follow your meal plan, then obviously you weren’t really feeling bad — if you were, you would have restricted.  Plus, when you are at a healthy weight — ta da, end of treatment!  You’re all better!  Even if you feel as crappy as ever, you’re not sick anymore, so…..

Thankfully not all professionals practice this way, but measuring your progress in recovery by numbers is not unusual.  I feel strongly that weight is just a piece of the puzzle… and while weight and eating are core components to eating disorders, by basing treatment on just these factors you are really limiting treatment.  There are people who will stay sick because the system inforces that they need to be to get help.  And that’s unfair…