Adults & Adolescents – In Treatment Together

I have mixed feelings about putting adolescents and adults together in treatment. I have been on both sides of the equation (treatment as an adolescent and treatment as an adult), and definitely have a stronger opinion about it now that I’m older.

Pros:

1. Adolescents can learn a lot from adults who often have been in treatment before and have some more insight into the disorder.
2. Adults are (hopefully) more mature and less competitive. Eating disorders in general are competitive… and I’ve just found that when you have a large group of ED high school females in a room, who are not necessarily in the best place, you could be in for a disaster. Sometimes just having a couple of older people in the room is enough to keep everyone from competing as much.
3. Adults can learn a lot from adolescents. They have a different perspective, and sometimes you need that.

Cons:

1. Being an adolescent and seeing adults in the group can cause some hopelessness that you’re never going to get better. It can give you the sense that people never really do get better and that you’re going to struggle with this the rest of your life.
2. As an adult, I often feel like a bad role model — especially if I’m having a hard time and an adolescent is doing well. I feel like as the older, “more mature” one, I should be responsible for setting the example.
3. Adolescents still live with their parents and (hopefully) their families are very involved in their treatment. I’m always a little jealous since my parents were pretty anti-treatment and didn’t (and still don’t) think that eating disorders are really problems. Sometimes interacting with others’ parents brings up stuff that you haven’t thought about recently (maybe that’s good, but it feels bad).
4. Adults and adolescents have different bodies, ideal weights, nutritional needs, etc. I know adults who have a really hard time being on the same meal plan as a 15-year old, with all the info they’ve heard about slowing metabolisms, muscle loss with age, etc.
5. Tiny, underweight adolescents are triggering. It’s hard to not compare yourself to someone who is 15.
6. Adolescents and adults are (obviously) at different stages in life. Sometimes it’s hard to relate to one another and certain sessions may not seem helpful for one group or the other.

This is just the start of a list — I’m sure there are 100 reasons. Personally, as an adolescent, I was really happy to be in treatment with older women. I really looked up to them and thought that they were so wise — they knew so much and had so much insight. There were a couple of people who I wanted to be like. There were also people who I did not want to be like, and it was motivating to me. I definitely told myself that I would NOT be one of those adults with an eating disorder. It wasn’t until I WAS an adult that I started feeling guilty about still struggling and/or being a bad example.

Anti-ED Coach

I’d never heard of a “Sober Coach” until watching VH1’s “Sober House.” In the last episode (I think), Will, who is Seth’s Sober Coach, accompanies him to his first concert and make sure that nothing happens to jeopardize his sobriety. While watching this I thought, “Well that’s convenient — I could use someone protecting me from anything eating disordered.”

Upon thinking about it a little more, though, I wasn’t sure what this Anti-ED Coach would protect me from. Would he make sure no one served me diet coke? Or that we only went to public places with healthy-weight people? Or would he stand outside the bathroom (any bathroom) and make me count? Okay, so maybe the idea was silly.

However, then I went and Googled “Sober Coach,” and found a website that explains what a sober coach does. Wow, they do a lot… they really seem like “life coaches” to me. If I had to adapt the list from this website for eating disorders, it would look something like this:

1. 24 Hour Crisis Support
   1. Phone support available 24 hours a day, 5 days a week.
   2. Education on how to ask for help.
2. Daily, Weekly, & Weekend Planning
   1. Creating an hour by hour schedule when necessary.
   2. Learning to deal with free time and/or unstructured time.
   3. Establishing weekly goals.
3. Physical Well-Being
   1. Nutritional consulting.
   2. Support with eating disorder issues.
   3. Support for anxiety and depression.
   4. Creating a personalized self-care plan (acupuncture, yoga, body coach, personal trainers, etc.)
4. Career / Academic Guidance
   1. Finding a job / volunteer work / internship.
   2. Support with changing careers.
5. Fun / Passion / Purpose
   1. Learning how to have fun & explore different hobbies.
   2. How to build fun into weekly schedule.
   3. Finding one’s own aspirations and dreams.
6. Recovery Support
   1. Help in finding appropriate treatment.
   2. Daily relapse prevention plan.
   3. Support in establishing healthy friendships and relationships.
7. Team Approach
   1. Works with psychiatrists, therapists, dietitians, and outpatient programs to provide a team approach.
   2. Referrals to various professionals as needed.

If you look at the original website, you’ll see that I didn’t have to add much. If Sober Coaches really do all of the above, that’s pretty amazing. I need someone to educate me on “how to ask for help” and “how to deal with free time and/or unstructured time” ! I also like the idea of someone coordinating things with a treatment team. I think that often professionals don’t work well as a team or they don’t necessarily consider the input of the patient (when appropriate). It’s a nice thought to think you could have someone advocating on your behalf in those meetings…

I realize that this is probably realistic, but it’s an interesting thought. An Anti-ED Coach could play a role that I don’t think really exists right now in treatment. Many of these responsibilities don’t fall under the job description of your doctor, therapist, or dietitian. It’s tricky relying on your spouse / family members to serve all of these functions, too, because they all don’t necessarily mess with the nature of the relationship. For instance, if I’m having a bad night and freaking out about something food-related, I don’t really want to make my fiance listen to my possibly irrational rant about calories. At the same time, though, it wouldn’t be appropriate for me to call or email my dietitian about this, either.

I am fortunate enough to have ED friends in recovery who can support me and give me advice during tough times, but that’s still a different relationship that with a Sober or Anti-ED Coach. You always have to consider if you are hurting or triggering the friend with your ED thoughts and behaviors.

Another strike against amenorrhea

I stumbled upon this article last week:  Metabolic Assessment of Menstruating and Nonmenstruating Normal Weight Adolescents This is something that I have always been curious about — is amenorrhea associated with a low metabolic rate?  I always assumed yes, at least a little bit.  However, I didn’t really base this conclusion on any hard science.  Let’s say that I used “Grey Science,” which goes something like this:

Your body requires a certain number of calories to function at full-capacity.  When you chronically deprive your body of these calories, it has to adapt to the calorie deficit to survive.  One of the ways that it does this is to cut out non-essential functions, like menstruation.  However, in recovery, it’s possible to gain weight without really restoring your metabolism (believe me).  If you’re still subsisting on a sub-optimal number of calories, then your body might still not feel like it can spare the extra calories that menstruation requires.  You are only able to maintain that weight on those calories because there are still processes that are being cut out.  This means that your metabolic rate is lower.

Again, this is my unscientific reason, that happens to make a lot of sense in my mind.  Thankfully some researchers came along to actually research this…

From the article:

“The purpose of this study was to investigate a possible mechanism for amenorrhea in adolescents who were  90-130% expected body weight with a history of anorexia nervosa, bulimia nervosa, or eating disorder not otherwise specified.  Using indirect calorimetry, we examined the metabolic differences between participants who were menstruating regularly compared with those who were amenorrheic.  Our hypothesis was that participants with amenorrhea would have a lower REE than those with regular menses.  We also proposed that both groups would have a lower REE than would be expected for age, weight, and height due to their dieting, calorie restriction, and eating disorder behaviors.”

And the conclusion:

“Using indirect calorimetry to assess REE, we showed that a hypometabolic state persists despite weight restoration.  There were significant metabolic differences found in weight-restored participants was amenorrhea as compared to participants who had regular menses.  Participants with amenorrhea consumed a lower fat diet, that a lower REE, and were at a lower mean body weight.”

So… overall, I was on the right track.  However, the article leaves me with several questions:

1. Why do recovered anorexics/bulimics have a lower REE than others their age without an ED history?
2. What is necessary for resuming menses?
3. I have been told by several doctors that often a stint on birth control is necessary to “jump-start” your period.  How does that relate?  And, how does that affect REE?

I think that the situation is a Catch-22.  Weight-restored patients with amenorrhea have a lower REE, so their metabolic rate is reduced and therefore need fewer calories.  However, they are still not getting their period, so do they need to be eating more?  I understand that you need to eat more to raise your metabolic rate and get your period back (in theory), but as a weight-restored anorexic I will tell you that my ED is screaming, “See!  You DON’T need that much food!  Your metabolism is slower!”  I think that it is a particularly difficult spot to be in since you can’t tell yourself “Well, you do need to gain…”  I am waiting for a follow-up study that shows that increasing caloric intake fixes said metabolic and menstrual issues.  Now THAT is a study I would be excited to read.

(Unrelated P.S. – This is the 100th Grey Thinking post!)

Greyisms (like Buseyisms)

It’s been a little while since I talked about Celebrity Rehab, but I have been meaning to write about Gary Busey’s “Buseyisms” (by the way, I highly recommend that you watch this — it’s less than two minutes long).  Buseyisms are really just made-up acronyms.  Backward acronyms, I guess, but you start with the acronym and come up with the meaning to match the letters.

I’m sure you’ve heard these before… like FINE – Frustrated, Insecure, Neurotic and Emotional.  Now, look at a few of Gary’s…

Doubt – Debating On Understanding Bewildering Thoughts
Romance – Relying On Magnificent And Necessary Compatible Energy
Fear – False Evidence Appearing Real
Fun – Finally Understanding Nothing
Sober – Son Of a Bitch! Everything’s Real
Fraud – Finding Relevant Answers Under Deception
Faith – Fantastic Adventures In Trusting Him

So, I thought that I would create some of my own, relating to eating disorder treatment.  Personally I don’t think they’re useful — I just think that they are amusing.  However, since it took me 2+ hours to come up with these couple of Greyisms, I think that they are a little less fun.  Anyway, here’s what I’ve come up with:

• Cope – Changing Overwhelmingly Problematic Experiences
• Shame – Sense of Hurt And Malicious Embarrassment
• Fear – Flee Emotions Around Reality
• Want – Wish About Needing Things
• Denial – Dismiss Every Notion Implying Anything Less
• Therapy – Telling Her Everything Rough About Previous Years
• Support – Someone Understanding Pretty Painful and Overwhelmingly Rejecting Thoughts
• Know – Kinda Not an Original Word

So there you go — those are my best Greyisms.  If you come up with better ones (which you will surely do), definitely post them!

More than stigmatization

There is definitely a stigma surrounding mental illness.  It doesn’t receive the same kind of acceptance as physical illness.  I’m not really going to get into stigmatization and society and whatnot, but I just want to make it clear that I believe that physical illness is much more understood than mental illness.

That said, I am a little disappointed to read this article on relationships and mental health:

A partner is four times more likely to leave you because of a mental health condition like depression than because of a physical disability.

The survey, which asked people about issues that would make them break off a romantic relationship found that 20 per cent of British women wouldn’t stay with someone if they were diagnosed with schizophrenia, yet only a few of them would break up with someone who became disabled and needed to use a wheelchair.

The article chalks up the entire discrepancy to stigmatization.  Naturally, I think that there are other elements contributing to this problem:

1. Personality changes – I think the biggest issue is that mental illness has a larger impact on your personality, mood, and temperament.  It’s not easy to be around someone who is really depressed.  You want to connect with your partner, spend time with them, and in general just be happy to be around them.  Most mental illnesses cause people to push others away, be irritable, isolate, etc.  These qualities are not very conducive to relationships.  In high school, my eating disorder definitely affected my relationships.  I didn’t want to go out to eat.  I didn’t want to see a late-night movie because I was too tired.  I took everything personally and was really depressed.  I was much more interested in the disorder than in my relationships.  I was not a fun date (to say the least).
2. Expectations of recovery – I think that it’s frustrating to be with someone who you feel should be getting better, but isn’t.  If you are in a wheelchair (to continue with the article’s example), you might never be expected to walk again.  However, if you have an eating disorder, you are expected to get over it.  It’s tiring to spend years and years worrying about someone who is continually in and out of treatment, rarely making significant gains in their recovery.  Your expectations are different.  Realistic or not, it can be exhausting to watch someone chronically struggle and feel like they don’t necessarily even want to get better.
3. You don’t know what you’re getting into. When you start dating a guy in a wheelchair, you know he’s in a wheelchair.  You very well may not know that your date is bipolar, though.  Again, it’s an expectations thing.
4. Baggage. As non-PC as this is, it’s true — mental illness carries a lot more emotional baggage than physical illness.  Someone with a mental illness is more likely to have a familial history of mental illness, childhood abuse, an alcoholic parent, or some other kind of trauma.  Eating disorders don’t develop in a vacuum, right?

Naturally, I wouldn’t discourage anyone from dating someone with a mental illness.  Actually, I don’t even like the “mental illness” label.  If we’re all on a mental health / mental illness continuum, then where do you draw the line, anyway?  (this is a discussion for another time!)  I just think that there’s a lot more at play than just stigmatization.