Sharing therapists

I’ve been in all different levels of treatment with numerous professionals and various treatment centers, and overall I’d have to say that both group and individual therapy are important (and beneficial) in recovery.  With group, there are several people who you can bounce ideas off of, get advice from, relate to, and rely on for support.  I feel like most of the real therapy work happens in individual, though, where you can focus on your specific issues, goals, etc.  I really do think it helps to have both individual and group components to your treatment plan, though.

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…

Caring makes you vulnerable

If you haven’t seen “In Treatment,” you definitely need to look it up.  It’s on HBO, so I would have never known it existed were it not for a good friend of mine.  Thank goodness she brought it to my attention, because I am so captivated by it.  While it can seem a little slow at times, the dynamics in the relationship between therapist and patient are so interesting.

Anyway, this past week I watched all seven weeks of April’s sessions.  I’m not going to summarize her whole story, but in the last episode she decides to discontinue treatment with Paul (therapist).  She says she can’t continue to see him because he saved her life.

This struck me as a little odd.  I was reading a blog post about it, and the author had a really good point:

“I think this is her way of preserving the feelings and experiences she has had with him, preserving them against the destructive urges she is still experiencing — in leaving school, in believing she cannot have love and a normal life. Leaving now allows her to continue to hold him as her savior…”

Now that makes a lot of sense to me.  She’s been through a lot of pain in her life that makes it hard for her to trust anyone.  She’s always taken are of herself because her parents are preoccupied taking care of her brother.  She probably thinks it’s not okay to have needs or to not be self-sufficient, because she has seen how her brother’s dependency has changed her mother’s life.  She has a pretty tough facade.

I think that on a deeper level, though, she really wishes that someone would really understand her and be able to reach her.  She needs someone to take care of her.  I don’t think that she put off chemo because she really wanted to die, but because she wanted someone else to be the adult and take care of her.

I can relate to that with the eating disorder.  I didn’t want to ask for help — I felt that if I really needed help, that someone would notice that I wasn’t okay and make sure I got help.  i knew that I was hurting my body and didn’t care.  Well, half of me didn’t care and the other half couldn’t understand the severity of the illness.  Never for a second did I think I was going to have a heart attack or end up with osteoporosis or anything.  But, that is like April — she was really sick with cancer and she was still waiting for someone to take care of her.  For someone to tell her that treatment mattered — that SHE mattered and that her health was important.  That she was worth taking care of.

Not only did she not want to have to ask for help, but I think that she felt guilty for needing help.  Not really guilty for having cancer, but that the cancer and her treatment were going to affect other people.  She cared more about not burdening her mother than saving her own life.  Again, I understand that — it’s easier for me to suffer than to hurt someone else.  I hate that my eating disorder affects other people.  I try to minimize the significance of it… not because I’m lying or trying to be manipulative, but because I don’t want to be a burden to my fiance, friends, or family.

I also know the feeling of your therapist being your “savior.” I don’t think I would have ever personally chosen that word, but when someone really does understand and connect to you on that deeper level… when they do just know that you’re okay and take care of you when you don’t ask… that’s valuable!  You have spent forever believing that it would never happen.  And now that there is someone in the world who can connect with you in that way, you’re afraid to lose it.  The thought of being let down by that person is too much to bear.  Or, even worse… what if you drove that person away?  You could ruin the relationship.

I have two theories on why April decided to discontinue treatment with Paul.

1. I think that sometimes when you get what you need, you can move on with your life.  April needed someone to take care of her in that moment and to show her that she mattered.  Paul repeatedly showed concern over her not taking care of herself and eventually even drove her to chemo.  She felt that loved — and that’s what she needed.
2. She wanted to think of Paul as her savior or caregiver, and not just her therapist.  He told her in the previous session that he couldn’t play both roles, and I think that she would rather pretend that he could than continue a relationship where he was just her therapist.  It’s less painful.

I know that I have jumped all around in this post, but basically — I could relate to a lot of the issues that April was dealing with (minus the very real threat of death… and losing my hair).  The therapeutic relationship between her and Paul was familiar to me.  I question her ending treatment with him, however, and am very suspicious that her decision was motivated by the fear of losing someone important.

The Rule of Thirds

Around one third of patients [with anorexia] recovery fully; another third improve significantly and the last third do not recover.

—Eating Disorders Factfile

I had a therapist explain this statistic to me once…

Group 1: Full recovery – The individual either recovers on her own or with treatment. The duration of the illness doesn’t really matter… what’s important is that the she goes on to live a relatively symptom-free life.

Group 2: Significant improvement – This could mean two things: Either the individual improves to a point where she can have a life with manageable symptoms or she “rides the ED roller-coaster,” so-to-say, with up and down periods of recovery and relapse. While the eating disorder still may affect her life, she’s a functional, productive member of society.

Group 3: Chronic illness — The individual is severely ill for most of her life (since diagnosis). Periods of recovery are brief (if existent at all) and all of her time is spent either consumed by the eating disorder or in treatment for it.

So, given these definitions, I decided that I was probably in group 2 (okay, go ahead and tell me that that’s the wrong mindset and that I could be in group 1 if I wanted to, etc. I am being realistic here). Kind of kiddingly I asked, “So, if you’re not in group 1, are you in therapy for life?” And her response: “Maybe–sometimes.”

WHAT! I only asked this question because I thought it was a pretty absurd question. She went on to explain that for the 2/3rds that don’t recovery completely, the goal is minimizing symptoms. Maybe you can go 6 months without treatment… and then after a year of going back to therapy and getting back on track, you can make it a full year without needing to see someone. The goal is always to get better… but if that means intermittent–or even consistent–treatment throughout your life, then that’s okay.

… thoughts?

The Bread Basket Dilemma

This question (turned argument) was posed the other night… Often when you sit down at a restaurant your waiter will come and sit a basket of bread (or tortilla chips if you’re at a Mexican restaurant) on the table–correct? Now, maybe you are recovering from bulimia and that basket of bread is really triggering. Is it disordered to say to the waiter, “No thanks, we don’t need the bread”?

Therapists response: Yes that is disordered because you should be able to have the bread on the table. If you are intuitively eating, you should be able to eat a piece of bread if you want it, or leave the basket alone if you don’t. That’s “normal.”

My thoughts: No, that’s not disordered–that is taking active steps to avoid a potentially bad situation. By asking for the bread to be taken away, you are taking care of yourself. You are acknowledging that the bread will tempt you to binge and instead of giving in to that urge you are saying “no thank you.”

I don’t think that recovery is about being 100% “normal”… but rather more like 95%. If you’ve struggled with anorexia in the past, then no, maybe joining Weight Watchers will never be okay. Sure, you should be able to stop losing when it’s appropriate… but why take the risk? Think about alcoholism–if you’re in recovery, should you meet your friends at a bar for an evening? Yes, you should be able to refrain from drinking… but again, why set yourself up for disaster?

To use a non health-related example, let’s think about money. People design budgets so that they don’t overspend. Maybe you should be able to have all of your money in the same place (we’re not considering investment returns here), but most people need that kind of structure. A little planning can go a long way.

So what are your thoughts? Where do you draw the line between healthy and disordered?

How quickly do you open up in therapy?

This could have been such a great article, had the question just been tweaked a little bit. (Therapy Watch: Diving In – How quickly should you open up in therapy?) Rather than “How quickly should you open up in therapy?” I think that “How quickly do you open up in therapy?” Or, since the article paneled all therapists…. “How quickly do your patients open up in therapy?”

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.

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