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…

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.

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.

Art therapy for everyone

I am officially the LAST person to blog about this study, but my thoughts seem to be pointed in a different from the other posts that I’ve read.

The Psych Central article, “Half of Young Adults Have Mental Disorder,” states the following:

“A total of 45.8 percent of college students and 47.7 percent of young adults not in college met the criteria for at least one psychiatric disorder.

The most common disorders in college students were alcohol use disorders (20.4 percent) and personality disorders (17.7 percent), whereas those not in college most frequently met criteria for personality disorders (21.6 percent) and nicotine dependence (20.7 percent).”

Now personally, I don’t lump alcohol use disorders and nicotine dependence under the umbrella of psychiatric disorders. Definite health problems — yes. Addictions — sure.

I think that Health News explained these results much more accurately:

“The effects of today’s lifestyles are taking some telltale tolls on many, and most especially on young adults. A recent analysis of more than 5,000 young people between the ages 19 to 25 has revealed that almost 20 percent of young adults in America have psychiatrics disorders that interfere with their everyday lives. Furthermore, the percentages of young adults who are abusing alcohol or drugs are even higher.”

20% is still a pretty alarming statistic, especially since the study found that “less than 25 percent of these college-aged youngsters who suffer from mental problems actually seek treatment.”

Laura Collins blogs that “it is obviously NORMAL if half of young adults have mental disorders.” Personally, I feel that when a majority of individuals of a disorder, that it is time to redefine “disorder.” Think, what if we considered yo-yo-dieting a diagnosable eating disorder? It’s definitely unhealthy and probably stems from personal issues, cultural expectations, other mental health issues, etc. but is it a disorder?

My point is that maybe the baseline of “normal” needs to be adjusted. I guess that there are two ways that you could approach this… either say that the quality of “normal life” should be lower (aka: moderate depression, anxiety, and substance abuse being the norm) or that society as a whole should be healthier.

Making society healthier is clearly the harder option. However, the first option of just accepting a degree of mental illness as a fact of life, is pretty depressing.

I would never say that all of these mentally-ill college students shouldn’t receive help… but I think when percentages start to reach this magnitude you need to look at global changes rather than specific, individual treatment. It is impractical (and nonsensical) to try and setup each of these kids with a therapist, psychiatrist, group therapist, etc. Counseling centers are already overloaded — no way could they handle that.

There is a lot of talk about the stigma that surrounds mental illness and its corresponding treatment. I don’t think that you can wait for this to subside to make mental health treatment more available, though. It needs to work in the opposite direction — first make treatment more common and easily accessible.

I think that college kids are much more open to getting help than others realize. My school had “stress reduction” as a PE class — and it was ALWAYS full. It was probably one of the hardest classes at the University to get into. Why aren’t there five of them? Why isn’t there a stress reduction group at the counseling center? I guarantee you that if there were a pre-med support group, that it would be packed. The pre-med track is stressful and probably causes a lot of the anxiety, depression, insecurity, and whatever else that causes more significant mental illness.

Why aren’t there art therapy groups at Universities? I was in IOP during my freshman year and my two best friends would kid that they wanted to make up eating disorders so that they could go to art therapy, too. Why do you have to have a significant mental illness to go to art therapy? Everyone could come up with something to process.

The system is setup so that you have to be sick to get help. The mental illness stigma is encouraged by the barriers to treatment. Seriously, create a program of “supportive groups” — regular misc. process groups, art therapy, stress relief groups, career-centric groups, psychodrama, grief & loss therapy, relationship issues group — whatever! I swear that students will come. If you offer a little more support to everyone, then treatment will seem less weird and fewer people will reach the point of needing intensive help.

Group therapy — where to draw the line?

Group Therapy May Help Memory

“Memory lapses could initially be caused by psychological stress. If the memory lapses are noticed, they can lead to anger and fear. Ultimately, this leads to heightened stress levels, which in turn increase the risk of memory lapses. This vicious circle capturing the sufferers is best characterized by models of somatoform disorders.”

So many studies (of different populations) have proven group therapy to be helpful: cancer survivor groups, alcoholics anonymous, grief & lost groups… there is definitely a lot to be said about sharing your feelings, relating to the experiences of others, getting advice, and giving some back.

I thought this article was interesting because of the direct connection between memory and mental illness…

stressor –> anger and fear –> heightened stress levels –> memory impairment

This isn’t really anything new… really post PTSD literature will tell you the same thing. You experience a traumatic event, it is too stressful (stressful can meaning scary, hurtful, etc.) for you to be able to handle/comprehend. You repress (or suppress — that’s another discussion in itself) the memory, but unconsciously/subconsciously it still bothers you. This distraction results in decreased memory function.

The biggest advantage of group therapy? Relating to others’ experiences and understanding more of your own. The biggest disadvantage? The trigger of these relatable experiences and the reliving of your own.

I’ve never been in an ED group that allowed talk about trauma. Even in the trauma groups I’ve been to, details of everyone’s stories have always vague. That’s pretty counterproductive, now that I think about it… discouraging talk about already isolating and taboo subjects… but there was some common understanding that sharing experiences with others could be a bad thing — you don’t want to bring up more trauma issues for anyone. You have to be careful.

I’m not sure how I really feel about those groups or that whole concept, and memory disturbance-causing stressors are probably rarely traumatic events… but how ironic that this treatment proposal is exactly what we were told not to do.

This is the same relationship between my ED treatment experiences and the Maudsley approach. I was always told that it’s not about the food — if you’re talking about the food, then you’re concentrating on that because it’s easier to obsess over that than to deal with more painful emotions. Not that Maudsley doesn’t involve any therapy (not making that assertion at all), but it strikes me as very “yes it IS about the food.”

I definitely keep up on psych research more than anyone I know… but it kinda makes you lose faith in the field. So much is contradictory… it’s not a hard science, so we don’t really know what works.

Maybe you can argue that treatment can be whatever you want it to be (you can definitely argue that different people require different kinds of treatment). I really believe that there has to be some more systematic approach to handling mental illness, though.

Therapists are like Starbucks Drinks

Choosing a therapist these days can be like ordering a drink from Starbucks:

I’ll have a grande CBT lite DBT Gestalt-free psychotherapy with two shots of psychoanalysis and breve IPT.

This image came to mind have after dinner with a friend last night. She’s been in therapy for several years, and has decided to switch to someone with “a little more of a CBT focus… who still integrates interpersonal therapy but spends less time talking about family.” Hmm… good luck with that search, Rach.

The reality of it is, there are so many types of therapy out there. Just to give you an idea of how many:

• Art therapy
• Cognitive-behavior therapy (CBT)
• Dialectical-behavior therapy (DBT)
• Exposure therapy
• Family therapy
• Gestalt therapy
• Group therapy
• Integrative psychotherapy
• Interpersonal therapy
• Hypno-therapy
• Marriage counseling
• Music therapy
• Narrative therapy
• Play therapy
• Psycho drama
• Psychoanalysis
• Psychodynamic psychotherapy
• Psychoeducation

… and on and on and on. Granted, some of these are much more common than others, and you could probably lump a lot of them together, but you see my point — what therapy is right for you?

No one therapy has been proven to be the best choice with eating disorders (especially anorexia), so your perception of recovery and ED etiology will be largely influenced by your first therapist. I think very few people have much information on all of the available types of treatment (not to mention the different kinds of therapists, psychiatrists, social workers, doctors, nutritionists, counselors, etc.). And even if they did… how do you know which therapy to try? And what exactly is the focus of therapy supposed to be? What is the interaction between you and your therapist supposed to be like? How are you supposed to feel when walking out of therapy?

There are so many beliefs in the psych field right now, that maybe you do need to customize your treatment like you would your Starbucks drink. And beyond that, maybe you’ll need to just around between types of treatment… not necessarily because you chose wrong in the first place (although that’s common), but because you have different needs at different times in your life and stages of your disorder.

Where this gets tricky, though, is with the concept of “bad therapy” — and if you’ve read my other posts, you’ll know that I believe that there is bad therapy. Maybe the kind of therapy that you gravitate towards is appealing is because it allows you to perpetuate your disorder or to ignore some issue. You can draw pictures forever in art therapy and never change any eating behaviors. Or, you can talk about your meal plan every single week with a nutritionist and never bring up a bad relationship that you’re in. So, I guess what I’m asking… is to what extent is therapy supposed to be comfortable? Is it no pain, no gain?

Any input would be appreciated…

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