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…

Positive self-help or self-hurt?

I’ve written several posts on the negative aspects of therapy as well as my disdain and frustration with positive self-talk, so I was pretty excited to see this headline: Study Shows The Negative Side To Positive Self-Statements In Self-Help Books

“…individuals with low self-esteem actually felt worse about themselves after repeating positive self-statements.”

“…paradoxically, low self-esteem participants’ moods fared better when they were allowed to have negative thoughts than when they were asked to focus exclusively on affirmative thoughts.”

Now, I don’t think I’ve ever claimed positive self-talk caused anyone to feel worse… but personally, I’ve never found it helpful as a coping mechanism. The results of the study do make some sense to me, though. Saying completely untrue statements like “I accept myself completely” make me feel further from that as a goal. I start to think, “Will I ever really accept myself completely? What’s wrong with me that I can’t right now? Does it matter if I do? Will I really feel better if I do?”

Also, the article makes a good point with being “allowed to have negative thoughts.” I think that often only positive affirmations are used in treatment in recovery. Things like “Everyone can get better,” “I know that you will beat this, you are such a strong person,” “You have too much potential to struggle with this forever,” “You’re making amazing progress,” etc. are all meant as motivational compliments. Maybe for some people they are… but again, I am backwards and actually feel a little invalidated when I hear how awesome I am doing in recovery. I don’t mind my therapist telling me I’ve made a lot of progress, but I do mind being told that I am doing great when I am feeling crappy. Additionally, sometimes I do worry that I will never get over this or that I will be considered “recovered” once I am 100% ideal body weight, regardless of whether or not I feel mentally/emotionally okay. I’d rather be told that she (therapist) knows that I am struggling and that she is there to support me, and that those fears are understandable becuase people do die from this illness or suffer from it their entire lives, but that I’m in treatment and working for something better than that.

I would love to see if there is a difference between others giving you affirmations vs. you creating them yourselves. I have a letter from an old therapist that says “you are more than enough” as well as a card from a different professional that says, “there are people who care deeply about you.” Both of these are comments that I could tell myself (I am lovable, my family and friends love me, etc.) but they are only significant because I care about and really look up to the people who gave them to me. I guess that’s what makes it so different from positive SELF-talk.

Numbers – a Catch 22

I read this post on Dads and Daughters With Eating Disorders: Eating Disorders – Weights & Scales

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…

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.

You've been in treatment too long if…

(in no particular order)

1. You measure the cost of things in nutrition appointments (ex: That shirt is one nutrition appointment. These shoes are worth two appointments).
2. You start dressing like your professionals (or maybe, they starts dressing like you…)
3. “Treatment” is a recurring event with no end date on your calendar.
4. You’ve never needed to purchase “Eating in the Light of the Moon” because at some point you have been given a photocopy of every chapter.
5. In group, no one sits in your seat, even when you’re not there (because you’ve been sitting there since last year).
6. The group therapist wishes you would just finish treatment already so that she could start recycling therapy topics.
7. You remember when some of the current therapists were interns.
8. You’ve modified the standard food log template to create your own (improved, of course)
9. Your therapist notices when you buy a new outfit (since she’s seen all of your other clothing).
10. When considering changing jobs, the new company’s mental health insurance is a deciding factor.

I am not guilty of all of these…. but more than a few.

You’ve been in treatment too long if…

(in no particular order)

1. You measure the cost of things in nutrition appointments (ex: That shirt is one nutrition appointment. These shoes are worth two appointments).
2. You start dressing like your professionals (or maybe, they starts dressing like you…)
3. “Treatment” is a recurring event with no end date on your calendar.
4. You’ve never needed to purchase “Eating in the Light of the Moon” because at some point you have been given a photocopy of every chapter.
5. In group, no one sits in your seat, even when you’re not there (because you’ve been sitting there since last year).
6. The group therapist wishes you would just finish treatment already so that she could start recycling therapy topics.
7. You remember when some of the current therapists were interns.
8. You’ve modified the standard food log template to create your own (improved, of course)
9. Your therapist notices when you buy a new outfit (since she’s seen all of your other clothing).
10. When considering changing jobs, the new company’s mental health insurance is a deciding factor.

I am not guilty of all of these…. but more than a few.

Letting it go

I started this day in a panic over insurance.  I hate insurance.  I know that is such a blind, ignorant statement, but at this moment (and a lot of other moments) I really do.

Unfortunately it is a holiday (well, that in itself is not unfortunate), which means that neither insurance nor my treatment provider is working.  There’s nothing I can do about it today.  I can’t resubmit my claim or beg for more days.  I don’t know if I will be going to my appointment tomorrow.

I don’t want to spend the next 24+ hours fretting over this, but at the same time, I do want to.  I know that worrying is not productive, but my mind is filled with “what if?”s and worst-case scenarios.  It’s as if turning it over and over in my mind will somehow prepare me for whatever happens tomorrow.

While trying to remind myself that worrying is not productive, I remembered this quote:

Behind all of this lay the “mind like water” concept … when you throw a pebble into a pond, what does the water do?  It responds with total appropriateness to the force and mass of the rock.  It does nothing more and nothing less.  It doesn’t overreact or underreact.  It doesn’t react at all.  It simply interacts with whatever comes to it and then returns to its natural state. – David Allen, Getting Things Done

So that’s my goal for today and tomorrow: “mind like water.”  I have to let it go for today.  I will try and be calm until hit with the insurance rocks.

I'm going to need that in writing.

I am not  an auditory learner.  At all.  I’m definitely a visual learner — in college I took copious notes, but didn’t really grasp the class material until later going over and reading those notes.  There’s just something about reading/writing that I need to get it.

Unfortunately, this doesn’t serve me too well in therapy.  I can have a great session and later that night not even remember half of what we talked about.  And on the same level, when I’m in session I don’t remember half of what I planned to say.

In an effort to make my time in therapy more useful, I’ve started to write things down.  Not quite journal, but write when I’m upset or just a couple of points I want to make sure that I let my therapist know.  If I’m afraid that I won’t bring up the issue in therapy, sometimes I’ll email them to her before my appointment.

That’s just one way that writing things down helps me in treatment.  Another is with my meal plan.  I know my meal plan backwards and forwards at this point, but one day I decided to pin it to pin it to my bulletin board above my desk.  This probably sounds silly, but it has made such a difference.  I am reminded all day that my meal plan and recovery are important.  When I’m in the middle of work I think “oh, I’ll eat that later” or “I am too busy right now,” but just having it written out and sitting in front of me helps me remember that treatment is important even when I’m not in my therapist’s office.

A third way is with affirmations.  Well, affirmations may not be the word that I’m looking for… but clips of little things that mean something to me.  For instance, also on my bulletin board is a fortune from a fortune cookie that says “Remember there are people who care deeply about you.”  I also have this paper on which my therapist wrote, “You can let go of your ED and still be validated” and “Never forget, but forgive and make yourself a better person.”  And then, sometimes I’ll print out pieces of funny or significant emails (from anyone in my life) and pin those up.  Yes, I have a very large bulletin board!

I need a written reminder for several reasons:

1. I’m a visual person
2. I twist things and second-guess myself and think “she didn’t mean it that way” or “I am reading into that too much.”
3. Being continually reminded helps me convince myself that it is true

Different types of therapy are helpful for different people, and I think that there is some trial-and-error involved in figuring out what works for you.  Personally, I highly recommend investing in a bulletin board.

I’m going to need that in writing.

I am not  an auditory learner.  At all.  I’m definitely a visual learner — in college I took copious notes, but didn’t really grasp the class material until later going over and reading those notes.  There’s just something about reading/writing that I need to get it.

Unfortunately, this doesn’t serve me too well in therapy.  I can have a great session and later that night not even remember half of what we talked about.  And on the same level, when I’m in session I don’t remember half of what I planned to say.

In an effort to make my time in therapy more useful, I’ve started to write things down.  Not quite journal, but write when I’m upset or just a couple of points I want to make sure that I let my therapist know.  If I’m afraid that I won’t bring up the issue in therapy, sometimes I’ll email them to her before my appointment.

That’s just one way that writing things down helps me in treatment.  Another is with my meal plan.  I know my meal plan backwards and forwards at this point, but one day I decided to pin it to pin it to my bulletin board above my desk.  This probably sounds silly, but it has made such a difference.  I am reminded all day that my meal plan and recovery are important.  When I’m in the middle of work I think “oh, I’ll eat that later” or “I am too busy right now,” but just having it written out and sitting in front of me helps me remember that treatment is important even when I’m not in my therapist’s office.

A third way is with affirmations.  Well, affirmations may not be the word that I’m looking for… but clips of little things that mean something to me.  For instance, also on my bulletin board is a fortune from a fortune cookie that says “Remember there are people who care deeply about you.”  I also have this paper on which my therapist wrote, “You can let go of your ED and still be validated” and “Never forget, but forgive and make yourself a better person.”  And then, sometimes I’ll print out pieces of funny or significant emails (from anyone in my life) and pin those up.  Yes, I have a very large bulletin board!

I need a written reminder for several reasons:

1. I’m a visual person
2. I twist things and second-guess myself and think “she didn’t mean it that way” or “I am reading into that too much.”
3. Being continually reminded helps me convince myself that it is true

Different types of therapy are helpful for different people, and I think that there is some trial-and-error involved in figuring out what works for you.  Personally, I highly recommend investing in a bulletin board.

Due next week: Therapy homework

Once in awhile, my therapist assigns me homework — usually for one of several reasons:

1. We only had time to touch on a subject in therapy and she wants me to keep thinking about it to flesh it out.
2. She wants to keep better track of my symptoms and I’m not very good at bringing up bad days (not because I’m manipulative and want to hide it from her, but because I never feel it’s “bad enough” to bring to her attention).
3. There’s something that I’m not able to say in person, and can much better articulate in writing.

I’m not anti-therapy homework, because it really is easier for me to write than to talk.  We started to talk about this in the comments of my last post, but I feel less uncomfortable and/or vulnerable when writing about issues than when talking about them.  Also, it’s helpful for me to be able to write and re-write my thoughts — I can spend 3 hours on that homework assignment if I want.  I can go back to old journals and do “research” (only I would come up with research for therapy homework!).  And…. I don’t have to necessarily be there when my therapist reads it, which means I don’t have to deal with the heavy emotions.

At the same time, though, I think a major problem with therapy homework is that it IS done at home.  Sometimes, if it’s a tough assignment, I end up really upsetting myself.  It’ll be 11:00pm and I’ll be sitting in my bedroom with old journals and reading things that I really should just burn.  My therapist isn’t there.  It could be a week until I see my therapist again.  Sometimes I’m still upset the next day, and it does affect my eating or mood.

Maybe I should put off any assignments until a couple of hours before therapy….