House, leashes, and noncompliance.

Dr. Wilson: House! Why the hell did you let an unstable patient wander the hallways?!
Dr. House: His leash broke.

I’ve always found the transition between “treatment” and the “real world” fascinating. One minute you are a “real adult” — you can drive your car, eat what you want, walk the dog, go to work, go on a vacation, make bad choices, make good choices… but as soon as you walk through those treatment-center doors, all of these adult “privileges” are revoked. Your purse and coat is locked up — you can’t carry your keys, because what if you tried to leave during the day? You ask permission to use the bathroom. Some people have to count while in the bathroom. You can have one packet of salt with your meal. No caffeine. No, you can’t see your weight–stand backwards on the scale.

And this isn’t just with residential treatment… but with day treatment or even IOP! Which makes it even more bizarre, because you wake up an adult, spend your day as a five-year old, and go to bed again that night as an adult.

I understand that it has to work this way for a couple of reasons:

1. There can be kleptomaniac patients.
2. Maybe someone is sick enough that they would get pissed off during a group and try to run off.
3. Treatment is about normalizing eating — which means not using 10 packets of salt on your meal.
4. Having unlocked bathrooms can create unnecessary temptations to purge. You’re there to work through the uncomfortableness of whatever you bring up in therapy and the normalness of the meals… without being able to use symptoms.
5. It’s easier to do okay when it’s not your choice, because then you don’t feel guilty. You didn’t give yourself permission to eat the meal — you HAD to eat it.
6. Not stressing over even the little things gives you more room to concentrate on the therapy.

There are already so many regulations in place. You are already being rewarded for eating and for drawing pictures in art therapy and for talking about whatever important issue. Heck, I have gotten praise for sitting still! (“grey, you sat still much longer than usual today — that’s definitely an improvement and I think that you need to learn to celebrate your accomplishments). So, when patients still find some way to evade the rules or act ridiculously helpless it irks me to no end.

I can relate to this House quote and the frustration of being in treatment with impossible patients. I understand having a hard time. You’re not always compliant in treatment because by nature, eating disorders are manipulative. But… the staff already has you on a leash. You don’t have responsibilities and you’re already being monitored. If you’re going to bring an extra set of keys with you to day treatment so that you can escape mid-morning and avoid lunch, the staff isn’t going to chase you. They shouldn’t have to!

Both inside and outside of treatment, you ARE still an adult. You still have some responsibility in cooperating. It’s the treatment center’s job to keep you as safe as possible and to reduce ED triggers and temptations. Therapists and counselors are there to help you in this already rigidly-structured environment — they can’t babysit you.

You as your own case manager

“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

I was watching Celebrity Rehab 2 online tonight (since I’m a little behind), and these words from Shelley really caught my attention. There are so many similarities between drug/alcohol recovery and eating disorder recovery…

I think that the eating disorder fools you into only doing what you “think it should take.” To give you some examples…

1. Target weight – “There is a healthy weight range, right? It’s easy to think that anywhere in this range is good enough. So what if it’s five pounds less than your target weight… it’s still healthy.”
2. Level of care – “I am fine with outpatient treatment – I don’t need IOP (intensive outpatient treatment). I’ll talk with a therapist once a week and that will help me to be accountable. I’ve had enough treatment and I know what I need to do. Now it’s just up to me to do it.”
3. Unhealthy environments – “So working as a waitress probably isn’t the best job for ED recovery… but I think I’m really a lot better now and will be able to handle it. Besides, I need to work. I’ll use the coping strategies that I’ve learned and will be fine.”

These are all easy arguments that the eating disorder makes… but what are wrong with these decisions?

1. The “healthy weight” zone is not the same as the “statistically most successful for ED recovery” zone. Besides, your body has some catching up to do and some damage to repair… all of which is going to probably require being above 85%. Maintaining a weight below your target weight doesn’t give you much room for error, either.
2. Why err on the side of not-enough treatment? If you start IOP and they tell you that you are great and don’t need that much support, then you can quit. Why risk your health and take the chance of it not being enough?
3. Putting yourself back in an unhealthy environment is just asking for trouble. You’ll need the coping strategies to just deal with new healthy environments. You need to at least set yourself up to be successful.

There are a couple of factors that separate “what it should take” and “what I think it should take”:

1. Giving up trying to control your treatment
2. Really being committed to getting better
3. Putting recovery FIRST in your life.

Probably the biggest problem with all of my examples is that the person with the disorder is making all of the decisions. You should not be your own case manager. Unfortunately, this is a tricky area because treatment is so variable and it’s not unlikely that you will run into a lousy treatment professional. Regardless, you can pretty much assume that whatever individual treatment decisions you want to make are a bad idea. The eating disorder is so manipulative and you’re not the best person to judge what you need. As hard as this is, you really do need to give up trying to control your treatment and just do what your team tells you to do (again, assuming that you have a good team).

It’s hard to tell whether or not you’re really committed to recovery. Sometimes I feel 100% committed… I’ll go to therapy, I’ll follow my meal plan, I’ll do whatever. But… if my treatment team were to decide to raise my target weight by a couple of pounds, I would probably be very resistant. Instead of thinking “I’ll do whatever the professionals think is best for me,” I’m thinking “That’s not fair. That wasn’t the original deal. I am not okay with raising that weight.” Clearly I am not 100% committed.

Putting recovery first is a sticky subject. I’ve gone through periods of feeling like recovery really was counter-productive because it was getting in the way of real life. Going inpatient means you’re not going to school or work — both things that create structure in your life, can be healthy outlets for anxiety, and can give you a sense of accomplishment outside of your disorder. Quitting so that your entire day can revolve around food and therapy sounds like a step backwards…. and maybe sometimes, it is. However, if your work is incompatible with your recovery (as maybe being a waitress would be), then you need to find another job.

It is so hard to trust your treatment to act in your best interest. Of course you want to make some of the decisions… you know yourself best, right? So often though, that’s the eating disorder talking. And while there are unhelpful professionals out there who may lead you down the wrong path (I once had a nutritionist tell me that I was “cured” and didn’t need any more help, 3 months out of inpatient.), you know when you are working with a good team. And in that case, they know what you need to do to recover. You just think that you know — and, as Shelly states, “it’s just not going to work like that.”

More House Wisdom

You think that the only truth that matters is that truth can be measured. Good intentions don’t count. What’s in your heart doesn’t count. Caring doesn’t count.

–Moriarty, House M.D. No Reason

The belief that “things don’t count” has always been a huge obstacle for me in recovery. Maybe originally I used the eating disorder to physically communicate something that I couldn’t verbalize… or maybe it was a manifestation of an unspoken problem that had to surface somehow. Or maybe I just had the biology + trauma = anorexia equation going for me. Whatever the case may be, the eating disorder has now been tied to emotional/mental health.

Eating disorders can be measured. Weight, weight loss, caloric intake, binges/purges, blood pressure, lab values, etc. Losing weight or weighing too little means that you are not okay. Gaining weight means that you are doing better. I could have an awful, depressing weekend… but gain a pound and think “well, obviously I wasn’t really upset, because then I wouldn’t have gained a pound.” That is so eating-disordered, I know, but my point is that eating disorders are measurable — and feelings are not. And while feelings should be more important, it’s hard to give them as much weight when there is physical evidence to the contrary.

The same goes when it comes to giving myself “permission” to take time out or to give myself a break. I have a career, expectations, responsibilities… what’s my excuse for not handling all of that — “I don’t feel okay”? Who cares? Does the world care? No. Because feelings don’t matter. I am physically okay, which means I am mentally okay (see previous paragraph), which means I should be able to handle everything. Everyone else can.

Of course I know that this is disordered thinking, and that sure, feelings do matter… But I can definitely relate to House on this one. The inside stuff doesn’t count because it’s not tangible. But, when you become physically ill… then there’s proof that something is wrong.

“All we’ve done is make a girl cry”

From an Episode of House, MD: Episode 3-12, One Day, One Room

In case you haven’t seen it, a girl has been raped and refuses to talk about the trauma. These are the last lines of the episode.

CUDDY: She’s gonna be okay.
HOUSE: Yeah, it’s that simple.
CUDDY: She’s talking about what happened. That’s huge. You did good.
HOUSE: Everyone will tell you… that that’s what we gotta make her do. We have to help her, right? Except we can’t. We drag out her story. Tell each other that it’ll help her heal. Feel real good about ourselves. But all we’ve done is make a girl cry.
WILSON: Then why did you…?
HOUSE: Because I don’t know.

Doesn’t this sound like the promise of therapy? That if you show up and talk about stuff that sucks, you’ll be okay? That’s at least the initial illusion that I had (similar to my inpatient treatment illusion — that you go away for a couple of months and come back okay).

So I went and I talked and I cried and I did not leave feeling okay. In fact I left feeling worse than before, and it took months (maybe years) to get back to my beginning neutral (apathetic) state. And I’ll admit that I had more insight than I began with, but if anything that just made some things in life harder for me (i.e.: particular relationships).

And then, after grieving my loss of hope that I would someday get over this, I moved onto accepting that “I just can’t be helped” (is that progress? probably not). It wasn’t really a “this is hopeless, there is not point in trying for the rest of my life,” defeat-like acceptance, though… but more of a “I am never going to work through this so I need to do my best to just ignore it” acceptance.

And that worked okay, because I finished school and formed meaningful relationships and functioned as a self-sufficient adult. But… then I went back and found a therapist. Why?

Well…. I don’t know. Because things weren’t quite right and I didn’t have any better ideas.

"All we've done is make a girl cry"

From an Episode of House, MD: Episode 3-12, One Day, One Room

In case you haven’t seen it, a girl has been raped and refuses to talk about the trauma. These are the last lines of the episode.

CUDDY: She’s gonna be okay.
HOUSE: Yeah, it’s that simple.
CUDDY: She’s talking about what happened. That’s huge. You did good.
HOUSE: Everyone will tell you… that that’s what we gotta make her do. We have to help her, right? Except we can’t. We drag out her story. Tell each other that it’ll help her heal. Feel real good about ourselves. But all we’ve done is make a girl cry.
WILSON: Then why did you…?
HOUSE: Because I don’t know.

Doesn’t this sound like the promise of therapy? That if you show up and talk about stuff that sucks, you’ll be okay? That’s at least the initial illusion that I had (similar to my inpatient treatment illusion — that you go away for a couple of months and come back okay).

So I went and I talked and I cried and I did not leave feeling okay. In fact I left feeling worse than before, and it took months (maybe years) to get back to my beginning neutral (apathetic) state. And I’ll admit that I had more insight than I began with, but if anything that just made some things in life harder for me (i.e.: particular relationships).

And then, after grieving my loss of hope that I would someday get over this, I moved onto accepting that “I just can’t be helped” (is that progress? probably not). It wasn’t really a “this is hopeless, there is not point in trying for the rest of my life,” defeat-like acceptance, though… but more of a “I am never going to work through this so I need to do my best to just ignore it” acceptance.

And that worked okay, because I finished school and formed meaningful relationships and functioned as a self-sufficient adult. But… then I went back and found a therapist. Why?

Well…. I don’t know. Because things weren’t quite right and I didn’t have any better ideas.

Dr. Drew should treat eating disorders

Just finished watching Dr. Drew’s Celebrity Addiction Special… and I’ll be the first to admit that I love Dr. Drew. I think that he is insightful, sensitive, non-nonsense, and passionate. I also think he has said one of the most true things about addiction: “You are as sick as your secrets.”

Eating disorders are different from drug / alcohol addictions, but there are definitely a lot of similarities. There are a lot of components of addiction treatment that I believe in and think are important, and should be applied to eating disorders:

Recovery is a lifelong, daily process — You may not struggle with food every day (heck, you could go years of being A-OK with it), but there’s always that risk. You don’t have the luxury of playing food games (and by playing food games, I mean even casual diets or schedules that don’t allow for normal eating). I would compare “I can have a couple of drinks” with “I can lose a couple of pounds.”

Denial, and not necessarily that you have a problem, but that you need help — Denial with EDs is particularly tough because they are not as black and white as other addictions… At what point does a lot of food become a binge? Where’s the line between health-consciousness and disordered eating? You may somehow know that your thoughts and behaviors aren’t completely normal… but not to a point where you require help. You’re still trying to convince yourself that you’re okay enough or that you can handle this on your own.

The importance of personal accountability — All the support in the world isn’t going to help you if you don’t take responsibility for the disorder. This means somehow sidestepping or pushing past the denial. No one is going to monitor your food intake forever, or follow you to the bathroom forever. If you’re not in a place where you can hold yourself accountable, then this means being responsible enough to arrange necessary help and support.

There’s no magic cure — 30 days of residential treatment doesn’t mean you’re recovered. Simply attending therapy doesn’t somehow fix things.

The disorder should be taken as seriously as any potential fatal disease — I really think that with eating disorder treatment, “slips” are much more tolerated and accepted than in addictions treatment. You can really get away with only putting forth a half-ass effort, because treatment isn’t necessarily your top priority. With drugs and alcohol, using once or twice is a big deal. With eating disorders… skipping a couple meals or losing a couple of pounds = not a big deal.

I personally find it interesting that you can dismiss so many little eating disordered things, because hey — people diet, you’re doing pretty well, it’s only a couple of pounds, purging every other month is insignificant compared to 3 times a day, etc. I respect Dr. Drew a lot because I always feel that he is saying, “no, these little things count — recovery is so important that any signs of disorderedness are significant.”

You are only as sick as your secrets…