First WHAT!? moment:

Participants were asked how the decision had been reached to avail of their various treatment options. Most participants had no involvement in any decisions pertaining to treatment.

WHAT? No way, I don’t believe that. I think there’s a BIG difference between treatment not being your idea and having “no involvement in any decisions pertaining to treatment.” I highly doubt that every person in this study was court ordered or dragged kicking and screaming into the treatment facility. Most of the people in the study were diagnosed in adolescence, so okay, maybe they HAD to go then… but the participants also all had “a lifetime history of AN.” As an adult, they CHOSE to get treatment. Even in Intervention (the TV series), you are given a choice — either get help or live a really difficult life where no one in your family will support you anymore. It probably doesn’t really feel like a choice, but it still IS one.

I know I’m fussing over semantics, but not taking ANY personal responsibility for your health / illness / treatment is a pet peeve of mine. I’ve had my fair share of anti-treatment periods, and can definitely separate the times I wanted help versus the times I didn’t, but the reality is that I DID show up for that doctor appointment. Maybe she “made” me go, but I could have immediately signed out. Staying in treatment is a decision.

Second WHAT!? moment:
(when talking about deciding factors for dropping out of treatment)

while for three participants (15%) the fear of weight gain was a major contributing factor to dropout.

Only 15% of patients would say that the fear of weight gain contributed to their decision to drop out / sign out of treatment? That’s just not honest. If everyone created a pros/cons list when considering quitting treatment, I bet that weight gain would be on 75% of their lists. Maybe it’s not in the top 3 reasons for leaving, but probably most patient’s top 10. Personally, I might not admit to my professionals that it’s a contributing factor, because I’d want to sound reasonable, rational, and believable (and definitely not want it to sound like a decision motivated by my eating disorder). Also, maybe I should clarify this is a list for dropping out of treatment — ending treatment because you’re ready or your team is ready to discharge you is different.

Anyway, I encourage everyone (who can get it) to read the article, and have a lot of other thoughts on it, but these few statements really stood out for me tonight.

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.

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:

Take the DSM-IV and add water.

Basically the new system expands each eating disorder category to be more inclusive, therefore reducing the percentage of sufferers in the EDNOS category.

How do they suggest doing this? Well…

1. decrease the specificity of each diagnostic category
2. remove concrete diagnostic criteria
3. rely primarily on clinical judgment for diagnosis

I think that by broadening each eating disorder type, they are creating more heterogenous patient populations.  Isn’t this a major criticism of the EDNOS diagnosis that they are trying to resolve?  I’m all for being more lax on the 85% of IBW rule (your diagnosis shouldn’t change just because you gain to 88%) and the frequency of binge/purge episodes, but as I said in my last post, diagnoses are meant to guide treatment.  Even from just a medical perspective, the anorexia diagnosis implies certain hallmark concerns – anemia, osteoporosis, low blood pressure, refeeding syndrome, etc.  Physicians know what to look for.  Research can be more accurate.  I think there are identifiable types of EDNOS patients and they should be classified as such, rather than getting lumped into another diagnostic category that only kind of fits.

I also take issue with their increased emphasis on clinical judgment:

“This scheme also offers an advantage for diagnosing individuals with eating disorders outside of specialist settings, where a comprehensive psychiatric assessment may not be feasible (e.g.. primary care)”

PCPs already often miss eating disorders… even with defined criteria and many present symptoms!  How will removing guidelines going to help them better diagnose patients?

What else bugged me about the study?  Well…

1. Individuals with a “lifetime eating disorder diagnosis” were excluded from the study
2. Course of illness, treatment approach, and treatment outcome were not considered
3. Anorexia was declared the most serious type of eating disorder, and therefore has the “highest position in the hierarchy.”
4. Diagnoses require significant functional impairment
5. Individuals are lumped into broad categories based on just BMI and functional impairment.
6. No definition of “recovery” or guidelines for when a patient is ready to end treatment.

I feel like this system takes current issues in eating disorder research, diagnosis, and treatment, and magnifies them.  Issues like specificity, chronicity, and the definition of “recovery.”

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.

I could not, would not, on a boat.
I will not, will not, with a goat.
I will not eat them in the rain.
I will not eat them on a train.
Not in the dark! Not in a tree!
Not in a car! You let me be!
I do not like them in a box.
I do not like them with a fox.
I will not eat them in a house.
I do not like them with a mouse.
I do not like them here or there.
I do not like them ANYWHERE!

I do not like green eggs
and ham!
I do not like them,
Sam-I-am.

–Dr. Seuss

There are more than a dozen interpretations of “Green Eggs and Ham” out there (just google it, you’ll see), but I’m pretty sure that mine isn’t one of them. When I hear the rhyme, I think of all the rules that individuals with EDs have surrounding food. Sometimes we’ll get a new patient who is not going to eat the meal if any of the following are true:

• One food is touching another food.
• Something requires a spoon.
• The food can’t be picked apart or cut into tiny pieces.
• There are caloric drinks (milk, juice, etc).
• Something is “not warm enough.”
• A piece of fruit has a spot on it (even a microscopic spot).
• The food can’t be eaten in a particular order.
• The room is too hot or cold.
• She’s sitting at the end of the table.

…and I could go on. I will definitely confess to doing some of these things. I hate juice and/or milk. My point is, though, that said new patient is against eating the food here, there, or anywhere. She’s wrapped up in the eating disorder and not even considering any of the above.

While I totally sympathize, part of me can’t help thinking “Well…. actually, you will eat your green eggs and ham – and you’ll (learn to) like it.” That’s kind of how treatment is. You come in screaming, “No no no! I will not I will not I will not! Not in a box or a house or even in the dark!” And you learn (or slowly realize) that not only are you going to eat them in the dark, but with a goat in a tree while it rains as well.

I re-watched Girl, interrupted the other day.  When I first saw the movie, I was in high school had just gotten home from my first ED inpatient stay.  The film actually made me homesick for the treatment center and all the girls there.  I was amazed at how well the directors portrayed the relationships and lives that are formed in an inpatient setting.

Anyway, now that I’m a little older and detached from the inpatient thing… I can appreciate the pure GENIUS that is this movie.  Maybe I’m exaggerating little bit, but there are so many little nuances that you probably can’t appreciate if you haven’t been inpatient before.

For example…
Susanna’s mother drove her to the psychiatrist’s office, but Susanna had to take a cab to the treatment facility – because “it will be less emotional that way.” That’s such a treatment thing to say.

Susanna’s parents took her to psychiatrist’s office.  Her psychiatrist told her she had to go for treatment and got her a cab.  The cab dropped her off at the front door of the treatment facility.  The nurse met her and walked her into the place.  And then… she is told that she has to sign the papers because she’s choosing to be there.  It is just like that!  Yes when you’re over 18 and not being committed, you are technically choosing to be there… but in this scenario, it doesn’t really feel optional and it was definitely not your idea.  They should change the words.  Instead of saying “you are choosing to be here,” they should say, “you are over 18 and not being committed.”

During the initial tour, Susanna and Valerie find Polly in the art room by herself – where she’s not allowed to be. Coming from the real world you’re thinking, “She’s not allowed to be in a room by herself?  What is she, three?”  It’s similar when you’re touring an ED facility and they are explaining that the bathrooms are locked and that you have to ask for permission to use them or count while you are in there.

Valerie tells Susanna that in a month she’ll likely have grounds privileges, and Susanna balks and says she’s not even supposed to BE there that long. That has definitely happened to me!  They told me I would have probably have exercise privileges in three weeks, and I explained that I was only STAYING three weeks total.  And I got that same kind of “okay then, don’t worry about that now” nod that Valerie gave Susanna.

Everyone always wants to know the others’ diagnoses. I think that’s normal human curiosity, and since everyone is in there for SOMETHING… While ED treatment centers are a little more dichotomous than general psych units, you still want to know what ED they have.

The first family session with Susanna’s parents starts with her mother describing a situation where Susanna rolled off the bed when she was changing her diaper. The trauma!  It’s all of the stereotypical “causes” wrapped up in one: blaming the mother, everything relating back to an incident in childhood, parental neglect or abuse…

Also in the first family session, the psychiatrist mentions mental illness being more common in individuals with a family history of mental illness. He may have well said, “maybe something is wrong with one of you, too.”  In ED intake assessments, they also ask about family history – and it makes sense.  They have to.  However, I think things start to get uncomfortable when the therapists start to ask about the parent’s eating habits and parenting skills.

Susanna isn’t told something about her diagnosis because it could “hinder her recovery.” Thankfully this is LESS prevalent now, but it still exists!!  Especially with personality disorders.  I’m not sure how NOT knowing your diagnosis would help your recovery, but would love to hear someone’s opinion on the matter.

They all went and got ice cream in a blizzard. I found this particularly funny, since more than once my dietitian has wanted to do an “ice cream challenge” in the winter.  We’ve never done one in the summer.

I’m sure that there are a 100 more nuances in the movie, so if you think of any, definitely comment!

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.